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U.S. NAVY MEDICINE 

May 1981 





3> 









Breaking Away From 
Alcoholism 




Surgeon General of the Navy 
VADM J. William Cox. MC" USN 

Deputy Surgeon General 

RADM rLA. Sparks, MC, USN 



U.S. NAVY MEDICINE 



Vol. 72, No. 5 
May 1981 



Public Affairs Officer 

LCDR Patricia M. Pallas. USN 



Editor 

Jan Kenneth Herman 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 
Nancy R. Keesee 



1 Features 

On Growing Children — Recurrent Abdominal Pain of Psychologic Origin 
CDR E. Breger, MC, USNR 

3 Soviet Naval Medicine: Aviation Medical Support (Conclusion) 
CAPTR.P. Caudill, Jr., MC, USN 



Contributing Editors 

Contributing Editor-in-Chief: CAPT E.L. Tay- 
lor (MC); Dental Corps: CAPT P.T. McDavid 
(DO; Preventive Medicine. CAPT R.L. Marior 
(MC); Health Care Programs: CAPT D.F. 
Hoeffler (MC); Family Advocacy: LT S.R. 
Doucerte. Jr. (MSC); Psychiatry: CAPT N.S. 
Howard (MC); Master Chief Petty Officer of 
the Force: HMCM S,W. Brown (USN): Special 
Projects: HMCM C.A. Crocker (USN) 



POLICY: U.S. Navy Medicine is an officii] publication of the 
Navy Medical Department published by the Bureau of Medi- 
cine and Surgery. It disseminates to Navy Medical Depart- 
ment personnel official and professional information relative 
to medicine, dentistry, and the allied health sciences. Opin- 
ions espressed are those of the authors and do not necessarily 
represent the official position of the Department of the Navy. 
the Bureau of Medicine and Surgery, or any other govern- 
mental department or agency. Trade names are used for 
identification only and do not represent an endorsement by 
the Department of the Navy or the Bureau of Medicine and 
Surgery. Although L'.S. Navy Medktne may cite or extract 
frum directives, official authority for action should be obtained 
from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navv Distribution List. The following distribution is author- 
ued one copy for each Medical. Dental. Medical Service, and 
Nurse Corps Officer; one copy for each 10 enlisted Medical 
Department members. Requests to increase or decrease the 
number of allotted copies should be forwarded to U.S. Navy 
Medicine via the local command. 

CORRESPONDENCE: All correspondence should be ad- 
dressed to: Editor. U.S. Navy Medtctne. Department of the 
Navy. Bureau of Medicine and Surgery (MED 001 D). Wash- 
ington. DC 20JT2, Telephone: (Area Code 202) 2S4-4253, 
254-1316, Autovon 294-1253, 244-4316. Contributions from the 
field are welcome and will be published as space permits, 
subject to editing and possible abridgment. 

The issuance of this publication is approved in accordance with 
Department of the Navy Publications and Printing Regulations 
(NAVEXOS P-351. 



10 MSC Survey Results: Attitudes Toward Professional Specialization (Part 
Four) 

LCDR P.T. Bruder, MSC, USN 
LTM.C. Butler. MSC. USN 

14 Tri-SARF: A Unique Facility Returns Patients to Duty 
J.K. Herman 

23 Professional 

A Simple Technique for Measurements of Percent Body Fat in Man 
LCOLH.F. Wright, USMCR 
CO. Dotson. Ph.D. 
P.O. Davis, Ph.D. 

28 To sBe Or Not To sBe (That is the Question!) 
CAPTR.E. Alexander, DC, USN 
G. W. Dennish, MD 

33 Notes and Announcements 



COVER: Alcoholism is the number one drug of abuse in the United States 
affecting between 12 and 15 million Americans. How a unique tri-service 
rehabilitation facility handles the problem is the subject of this month's cover 
story on page 14. Cover art and design by Juanita Adams. Cover photography 
by HM2 Kevin Kaya and HN Bobby Brown. 



NAVMED P-5088 



On Growing Children 



Recurrent Abdominal Pain of 
Psychologic Origin 



CDR Eii Breger, MC. USNR 



"An hour of pain is as long as a day 
of pleasure." English Proverb 

Every parent and physician is fa- 
miliar with the "stomach ache" of 
which children sometimes complain 
as part of a generalized infection or 
emotional stress. Children may also 
use it as a manipulative device to 
avoid an unpleasant task or for no 
apparent reason. Studies in pediatric 
outpatient departments reveal that 
approximately 10 percent of children 
presenting themselves do so because 
of abdominal discomfort. In only five 
to ten percent can a substantia] 
physical basis be found to account for 
the problem. 

There is a smaller but significant 
group of children who complain 
recurrently and persistently of severe 
abdominal pain. However, no tangi- 
ble disorder is revealed upon re- 
peated and extensive physical evalua- 
tions. One can sense from this that 
the symptom may represent the final 
focus of many and diverse psycho- 
logical issues within the growing 
child. These children are of deep con- 
cern because they suffer severely and 
their lives and happiness are marked- 
ly impaired. We refer to their condi- 



Dr. Breger is Chief of the Psychiatry Service 
al the Naval Hospital, Beaufort, SC 29.902. 
Copyright 1981 Eli Breger, M.D. All rights 
reserved. May be reprinted or reproduced 
within the Navy for nonprofit educational 
purposes in keeping with the fair use doctrine. 



tion as recurrent abdominal pain of 
psychological origin. 

If untreated, the symptom has a 
rather poor outcome. Long-term fol- 
lowup studies of untreated children 
reveal that one-third persist with 
similar symptoms, another third un- 
dergo symptoms replacement such 
that they now have pain in other parts 
of the body, and only about a third 
are symptom-free. These recurrently 
complaining children present them- 
selves in late childhood or early 
adolescence, although quite fre- 
quently they had complained of simi- 
lar symptoms earlier that were in- 
variably of brief and mild intensity. It 
is as if their earlier experiences were 
stored in their memories to reappear 
as more complex psychosomatic re- 
sponses when they developed stress- 
ful life problems. Their level of in- 
tellect and neurologic development 
must also reach a point to make this 
response possible. In almost all psy- 
chological presentations, boys out- 
number girls. Interestingly, and in 
contrast, girls complaining of this 
condition appear far more frequently 
than boys. The reason for this is un- 
certain. It may be because boys are 
able to discharge aggressive feelings 
more adequately in play and so are 
less burdened by these emotions. 

Presenting Features 

The clinical features of the condi- 
tion vary from child to child as we 
seem to be dealing with a common 



endpoint to several conditions. Most 
often, the child had shown relatively 
frequent stomach aches over a num- 
ber of years with periods of symptom- 
free functioning lasting from months 
to a year. Usually the pain is 
moderate, vague as to description, 
and localized around the navel area. 
Description of the pain is most often 
detailed by the mother rather than 
the child showing very deep identifi- 
cation between the two with an over- 
protective and highly anxious mother 
and an overly dependent child. The 
pain is rare during sleep. Physical 
examination and workup are usually 
negative and, in spite of the pain, 
there does not appear to be much 
abdominal tenderness or bloating. 
Quite frequently, the symptom is as- 
sociated with nausea, vomiting, 
headache, and pallor, but the ab- 
dominal pain remains the central 
complaint. At times, the onset is re- 
lated to an obvious environmental 
stress but this is the exception rather 
than the rule. It is rarely difficult to 
come up with some stressful life 
situation occurring around the onset 
of a physical symptom, but it is 
harder to prove it is the cause. Most 
often, the onset is related in a general 
way to unconscious psychologic is- 
sues involving anxiety, anger, or 
guilt. These emotions are held in 
check by the child's burdened de- 
fense system until an imbalancing 
takes place. Only a very thorough and 
detailed study of the child and the 



Volume 72, May 1981 



environment allows us to understand 
what has been taking place and why 
the difficulty has occurred. 

Parents of these children usually 
are illness oriented. In their search 
for a physical cause they will accept 
almost any explanation offered. With 
such a pronouncement by a physi- 
cian, even when the supposed cause 
is of serious consequence, there is 
often a relief in symptomatology. It is 
as if such families thrive on crises 
and suffering and anxiety decreases 
once they have something tangible on 
which to concentrate. It is regretful 
that such children undergo repeated 
medical workups and are prone to 
multiple surgical procedures recom- 
mended by physicians confused by 
the clinical picture and eager to avoid 
overlooking a concealed abdominal 
condition. Often, appendicitis is sus- 
pected and when appendices are 
removed they invariably turn out to 
be free of disease. However, a tem- 
porary improvement in the child's 
suffering takes place making the 
family and physician believe they 
found the basis of the problem. How- 
ever, in a matter of months or a year 
the condition returns. 

Child's Personality 

The personalities of such children 
tend to be rather characteristic. They 
appear to be older than their years, 
neat, orderly, bright, and conform- 
ing. Parents refer to them as "my 
best child." This personality profile 
is typical of most individuals with 
psychosomatic conditions. It reflects 
great restraint over the expression of 
negative emotions and feelings with a 
deep subtle reservoir of fearfulness. 
The parents tend to be responsible 
and sensitive individuals with high 
expectations for themselves and their 
children. They obviously are chroni- 
cally worried and share with the 
doctor anxieties not only about the 
child but about other issues within 
the family, past and present. Often 
there is a history of some major stress 
within the family having taken place 
during the child's early development. 



The raising of this particular young- 
ster then becomes imbued with a 
great deal of anxiety which is trans- 
mitted to the child. A lack of 
confidence in the youngster's ability 
to develop normally and naturally 
emerges and there is strict parental 
surveillance and involvement on 
every level. The child remains de- 
pendent and learns to suppress con- 
flictual feelings, expressions of which 
are so necessary for growth and com- 
petence. In time the child, although a 
model of conformity, is also per- 
ceived as being less capable, weak, 
and sensitive. This intensifies the 
parents' view that their careful pro- 
tection has been justified. 

Family History 

Frequently, a parent or close rela- 
tive has or did have similar symp- 
toms. This individual generally is 
pain-prone and illness-oriented and 
offers himself as a model for identifi- 
cation to the child. Guilt can play an 
important part in such relationships. 
As these children do not live well 
with their conflictual feelings, they 
may feel guilt because of their 
natural ambivalent feelings toward 
their parents. To allay this guilt they 
identify with the suffering symptoms 
of their parents and both complain of 
recurrent abdominal pain. 

Most of these children are dis- 
turbed on deep levels as described 
above, but occasionally a more 
superficial cause can be found. A 
child may by chance learn that such 
discomfort makes him the recipient of 
much attention and diverts it away 
from other problems such as parental 
arguments and threat of separation. 
On an even simpler level, it may be 
learned as an effective means of 
avoiding an intolerable school situa- 
tion. 

Early Pain Experiences 

Though such reactions appear 
complex, this is the nature of the re- 
sponse. It becomes more plausible 
when we consider that pain in earliest 
life is simple at its basis. Pain reflects 



irritation to external nerve endings 
which move inward and ■' upward 
along the central nervous system 
where it is experienced as pain by the 
brain. A variety of defenses and pro- 
tective reactions is then marshalled 
on the part of the baby. Pain is 
always psychological in its final 
awareness within the brain. Before 
long, the growing child has de- 
veloped pain memories which include 
discomfort giving rise to reunion with 
the reassuring mother, atonement for 
guilt feelings following a physical 
punishment, the intensity of pain 
involved in aggressive interaction, 
and the like. In time, therefore, 
emotional factors previously asso- 
ciated with peripheral pain of realistic 
external origin become displaced on 
to later and more complex internal 
emotional life issues. 

Advice to Parents 

It is wise and prudent for parents 
to be aware of this condition. Com- 
mon sense appraisal of family ten- 
sions, parental overprotection, and 
anxiety regarding the child, as well 
as the child's personality, should all 
be kept in mind with adjustments 
made to alleviate problems. The ad- 
vice of a physician is invariably 
sought. An appropriate attitude by 
the parent can go a long way toward 
helping the doctor. He would not feel 
under pressure to launch a "witch 
hunt" to find some obscure physical 
basis for the condition. In spite of 
negative physical findings extensive 
procedures often place a "physical 
illness stamp" on the condition which 
becomes deeply engrained in the 
child's mind. The treatment of choice 
is early identification with manage- 
ment in a common sense and psycho- 
logically oriented fashion over a long 
period of time. Quite frequently, a 
more intensive psychiatric undertak- 
ing becomes necessary. 

"Much of your pain is self-chosen. It 
is a bitter potion by which the physi- 
cian within you heals your sick self." 
Gibran □ 



U.S. Navy Medicine 




Soviet Naval 
Medicine 

CAPT R. Paul Caudill, Jr., MC, USN 



Aviation Medical Support 



Conclusion 

Review of Soviet military medical 
literature for articles discussing the 
Soviet flight surgeon, or "air physi- 
cian," revealed much about various 
topics of concern to aviation medical 
support, the education of flight sur- 
geons, and the practice of aviation 
medicine. 

Senior Soviet military medical au- 
thorities discussed in considerable 
detail the professional competence 
and identity of the flight surgeon in 
the Soviet military. In introducing 
their discussion, the authors pointed 
out the increasing complexity of the 
aviation environment and the radical- 
ly increasing demands on the human 
system charged with manning the 
airborne weapons systems. As the 
complexity of the mission, system, 
and task-loading increased and the 
cost of systems expanded, the fitness 
of the human system for mission 
performance was of greater im- 
portance than ever. Thus, the flight 
surgeon in the Soviet Union appeared 
to be facing the challenge of support- 



Dr. Caudill is Commanding Officer of the 
Naval Aerospace Medical Institute, Pensacola, 
FL 32508. 



ing the human factor in that complex 
equation. The flight surgeon's re- 
sponsibility in that role was greater 
than it had ever been.(i) 

Preventive medical work in the 
aviation unit, health monitoring of 
flight crews, and preflight medical 
checks required a broad spectrum of 
skills. These abilities demanded com- 
plete insight into mission perform- 
ance demands so that psychomotor 
findings could be correlated with 
mission demands. In the words of 
Soviet authors: 

In this article, there is no neces- 
sity for enumerating all of the 
numerous duties of the aviation 
chast [unit] doctor. It is only im- 
portant to note that for successful 
performance of these duties, the 
aviation doctor must have special- 
ized training differing from the 
training of the doctors in the other 
branches of the Armed Forces. (2) 

Aviation medical training was not 
seen to exclude broad general clinical 
competence. The authors spoke of a 
still existing idea that practical avia- 
tion medicine has little in common 
with clinical medicine. This point of 
view is not only false but can be of 



definite harm. It leads to a lag in 
work techniques and the capabilities, 
of aviation doctors being assigned the 
level of medical science and a lower- 
ing of the medical qualifications. (3) 

In an article which subsequently 
responded to the comments on clini- 
cal medical importance, Doctor of 
Medical Sciences, Colonel of the 
Medical Service, V.A. Ponomarenko 
discussed the view of the relationship 
of professional knowledge to the 
requirements of the aviation practice. 
He pointed out that the flight surgeon 
must have more than broad clinical 
and theoretical knowledge concern- 
ing aviation. In order to have "au- 
thority" in the aviation unit, the 
doctor must study the social and 
psychological peculiarities of the 
aviation community, the personalities 
of pilots, and the social atmosphere 
in which the flight and engineering 
crew lives and works. He felt that the 
flight physician's credibility with his 
unit members was tied closely to his 
insight into, and knowledge of, the 
unit mission and in-flight work. 

The mission of the unit and the 
work performed in flight were seen as 
having a "channeling effect" on the 
personality of individuals serving in 
the unit. Ponomarenko concluded his 



Volume 72, May 1981 




Soviet aircraft carrier Minsk underway off the Philippine coast. 



comments by stating his opinion that 
the flight surgeon had a great role to 
play in the operational aspect of unit 
training and mission accomplish- 
ment. However, in a footnote, the 
editors of the journal rejoined by stat- 
ing that his view was his own, and a 
one-sided one at that. The view of the 
editors of the journal was that the 
primary role of the aviation physician 
was medical support of flights, pre- 
ventive medicine, and participation 
in flight examination. In the opinion 
of the editors, the physician's credi- 
bility depended more on his clinical 
efficiency in those roles than on his 
ability as an operational expert. (4) 

Major General N.M. Rudnyy, et 
at, wrote the following: 

Every aviation doctor who has 
worked in the chast [unit] for a 
prolonged period of time can con- 
firm that his expertise which pro- 
moted the success of his work de- 
pends to a high degree on what 
kind of doctor he is in the ordinary 
sense of the word, how qualified 
he is when it is necessary to state 
a diagnosis and give medical aid, 
to establish reliable sincere rela- 
tions with the personnel, espe- 
cially the flight personnel, to 
penetrate into their needs and 



their lives with observation of the 
rules of medical ethics. (5) 

In summary, Soviet authors be- 
lieved a flight surgeon must be clini- 
cally competent to perform the 
overall aviation medical task. They 
realized, simultaneously, that it 
would be impossible for the flight 
surgeon to be all things to all men. 
They felt the aviation physician 
should have a thorough, well- 
grounded clinical education, and that 
each aviation specialist should pur- 
sue rationally the orderly mainte- 
nance and increase of both general 
clinical skills and aviation- specific 
knowledge. (6) 

Several writers favored two pro- 
grams that had to do with establish- 
ing certification for flight surgeons. 
They discussed two general concepts. 

• Periodic certification of general 
competence. 

• Establishment of three skill level 
designations for flight surgeons. 

Periodic recertification would en- 
courage physicians to work to main- 
tain their intellectual and clinical pro- 
ficiency. The skill level designations 
would present goals worthy of profes- 
sional pursuit, providing recognition 



and distinction to the achiever. {7,8) 
Continuing clinical education was 
also viewed as being important. It 
was recommended by one author that 
flight surgeons be sent, at least once 
every two or three years, to medical 
refresher courses. (9, 10) 

A physician assigned as a chief 
flight surgeon had to be mature. 
Soviet experience had shown that it 
was preferable for an individual to 
have worked for a year or two as a 
junior physician before assuming 
duties as the chief flight surgeon for 
an aviation unit. Those just out of the 
Military Medical Academy did not do 
as well as those who had acquired 
training and experience in areas es- 
sential to the support of aviation units 
and developed both skill and experi- 
ence in the practice of clinical medi- 
cine. (11) 

The importance of maturity and 
clinical competence was paralleled by 
the need for insight into the peculiar 
aspects of aviation medicine. Soviet 
flight surgeons were tasked with 
making individual decisions about 
flight crew readiness for each flight 
that took place. Every member of the 
aircrew had to be certified as fit for 
flight. Such decisions required artful 
insight as well as academic and clini- 
cal skill. 



U.S. Navy Medicine 



It is sometimes more complicated 
to arrive at the conclusion that a man 
is healthy and ready for flight than it 
is to make a diagnosis that he is sick, 
especially if we consider the usual 
desire of pilots to carry out the 
planned flights and their known in- 
clination to dissimulation. (12) 

One article emphasized the im- 
portance of the role of actively par- 
ticipating senior physicians. Senior 
medical officers were tasked with re- 
sponsibility of monitoring and shep- 
herding the continuation of profes- 
sional education of the younger flight 
surgeons. Independent study, medi- 
cal conferences in nearby hospitals 
and medical units, and consultation 
with specialists and more experi- 
enced colleagues were encouraged. 
Finally the article stated that senior 
medical officers should see to it that 
the young aviation doctors received 
active medical practice training re- 
gardless of the impact of their 
absence on the routine of the local 
medical facility in which he was 
serving. (13) 

Omissions in clinical training and 
experience were seen to influence 
even the routine periodic medical 
examinations of flight crews, result- 
ing in less than professional prac- 
tices. The basic problem in this area 
is the insurance of an optimal com- 
bination of good training with respect 
to all divisions of aviation medicine 
with sufficient knowledge of the 
clinical disciplines and skills in medi- 
cal thinking. (14) 

The work of the Soviet flight sur- 
geon lay in close proximity to mem- 
bers of the flight crew. Aviation 
physicians examined Soviet aircrews 
before participation in assigned mis- 
sions and the physicians certified 
them as fit or unfit for flight. 

One article discussed the environ- 
ment in which the flight surgeon was 
supposed to perform. Experience had 
shown the Soviets that the best 
monitoring of aircrew fitness general- 
ly occurred in aviation units that had 
the best facilities and equipment for 
the physicians' use. Such facilities 



included a well-equipped medical aid 
station and a proper examination 
room for preflight medical examina- 
tions. The examination room was 
supposed to include the "latest ap- 
paratus by means of which one can 
objectively record any changes in the 
pilot's organism." It was noted that 
there was, at the time the article 
was written, no standardization of 
examining facilities and equipment. 
(15) 

At some bases, there were "multi- 
story rest accommodations and engi- 
neer control points" including a room 
for flight crew preflight examina- 
tions. However, noise from aircraft 
was said to often complicate both 
flight crew rest and medical evalua- 
tions. (26) 

The literature also noted the im- 
portance of considering aeromedical 
support in construction of systems 
"for the centralized servicing of air 
technology," so that examination 
rooms would be adequate and func- 
tional. 

Soviet flight surgeons' responsi- 
bilities went beyond the examination 
and treatment rooms. Physicians 
participated in analyzing the per- 
formance of pilots and flight crews 
through mission evaluation. Analyti- 
cal methods included examination of 
radio communication information ex- 
change, tapes from automatic flight 
recorders, and radar plots of the mis- 
sion. Evaluation of landing tech- 
niques, and postflight pilot medical 
examinations after flight incidents 
were other methods described. 

"In the process of flights, the air 
physician must constantly check the 
pilot's state of health and his work 
capability, he must be aware of all 
events occurring in the air and on the 
ground. "(17) 

A practical problem faced by the 
Soviet flight surgeon was one which 
concerned the manner in which he 
was expected to approach accident in- 
vestigations such as forced landings 
or ejections. It was noted that at the 
time of the article's publication, April 



1978, there was no "directive docu- 
ment" sufficiently specific in dealing 
with the responsibilities of the chief 
of the medical facility supporting the 
aviation unit and the duties of the 
unit flight surgeon in case of such 
accidents. 

"The fact that no such description 
exists cannot fail to have an effect 
upon the work performed by the 
medical service. Therefore, young 
physicians arriving in the chast [unit] 
do not always have a clear idea of the 
work volume that they will have to 
perform." (18) 

Additionally, 

"At the present time, the training 
of air physicians in air physiology is 
irreproachable, but their knowledge 
with regard to questions of the medi- 
cal analysis of erroneous actions re- 
quired deepening. "(19) 

The Soviets had some experience 
with the training of physician avia- 
tors, or had, at least, considered such 
training, 

"The available experience in train- 
ing flight doctors has demonstrated 
that it does not appear possible to 
maintain the knowledge and skills 
with respect to these two professions 
of the required level in the future, for 
each of them requires total effort." 
(20) 

Practical research in support of 
operational tasks was said to go on 
routinely. In one example, the author 
had sought to devise a relatively 
simple set of tests to evaluate the 
presence of excessive fatigue in flight 
personnel. He used "simple psycho- 
physiological procedures" such as a 
reaction to a moving object, memory 
tests, simple arithmetic problem, 
tremor, dermographia, and hemo- 
dynamic indices after functional load 
testing with simple exercises. The 
physician hoped to provide the flight 
surgeon the "possibility of discover- 
ing initial signs of overfatigue of the 
flight crew. "(21) 

Another physical problem encoun- 
tered among Soviet aircrews was 
overweight. One article described a 
study of patterns of overweight and 



Volume 72, May 1981 



obesity among pilots and flight 
engineers. 

It is necessary to discover the 
people with increased body weight in 
time and continuously to put them on 
the report, to conduct explanatory 
work among them on the unfavorable 
effects of obesity on the state of 
health. It is necessary to recommend 
that these people increase their 
physical load {after careful medical 
examination and under the control of 
the doctor), reduce their consumption 
of high-calorie food, and so on. The 
performance of the indicated meas- 



ures and the fulfillment of the 
enumerated recommendations will 
permit a decrease in the number of 
overweight pilots and engineers. (22) 
Soviet naval units with aviation 
missions had concerns about ade- 
quacy of aeromedical support. On 
those Soviet ships with helicopter 
units, the helicopter crews experi- 
enced both physical and mental 
stress in their work. They were often 
faced with complex assignments, 
emotionally stressful solitary low- 
level flights, independent decision- 
making, heavy skill demands, and 



constantly changing environmental 
challenges, both shipboard and 
geographical. 

Great concern was expressed about 
physical and mental stress. Crew 
selection was of great importance in 
this respect, and the ships' surgeons 
required education in aviation medi- 
cine and methods of monitoring 
stress. 

Ships' physicians were responsible 
for checks of aircrews before, during, 
and after flights. The surgeon was 
responsible, also, for monitoring the 
aircrew environment, their work and 




Stent deck of the Soviet aircraft carrier Kiev. 



U.S. Navy Medicine 



rest patterns, and their health status 
with regard to diet, exercise, etc. 
There was emphasis on physical 
Fitness. In summary, a ship's physi- 
cian was responsible, for monitoring 
of: 

• living quarters 

• nutrition 

• physical training 

• observance of preflight work and 
rest routines (23) 

Helicopter crews afloat were inter- 
mittently tasked with the evacuation 
of sick and wounded from naval and 
merchant marine ships. This was 
accomplished by a variety of methods 
reported in a 1967 article. (24) 

Swinging ladder 

• healthy individuals only 

• climb holding only one side of the 
ladder with its position between the 
legs of the climber 

• heels in, toes out herringbone 
climbing pattern 

• one on the ladder at a time 

Suspension system 

• similar to parachute harness 

• hooked to winch cable 

• hoisted in sitting position 

• left them 1.5 meters out from the 
helicopter door so entry was some- 
what difficult 

D-ring 

• cork/leatherette wrapped cable 
similar to the U.S. collar, under arms 
around back of patient 

• fastened in the front of the patient 

• contraindicated for severe chest 
wounds 

• contraindicated for fractures of 
spine 

• contraindicated for injury of upper 
extremities 

• contraindicated for patient inclined 
to orthostatic collapse 

Stille stretcher 

• fastened with straps 

• raised vertically if possible 

• horizontal if cannot lift vertically 



• guy wire attached to head of the 
litter to control litter oscillations, and 
to keep it from snagging under the 
helicopter 

Ship's stretchers were occasionally 
used with patients' legs hanging. A 
more difficult technique was required 
for a lift by such a method. 

Experience had shown that the 
helicopter crews had to be constantly 
wary of the masts of small ships. The 
author of the article recommended 
that only experienced aircrews be 
used for small ships operations. (25) 

At the present-day stage of avia- 
tion development, the air physician 
plays an important role in questions 
of maintaining flight safety, preserv- 
ing the health of the flight personnel, 
and prolonging flight longevity. He 
must constantly keep in his field of 
vision everything that occurs during 
the flight day, he must know the 
psychological and physiological state 
of the pilot who has made the flight 
and who is preparing for an even 
more complicated mission. He must 
know the pilot's everyday living con- 
ditions, his moods, the overall condi- 
tion of his organism, the parameters 
of his physiological functions; for that 
will determine the correctness of the 
conclusions relative to certifying the 
pilot for flight. (25) 

The results of articles concerning 
aeromedical support of Soviet avia- 
tion was, in many instances, like 
reading a chronicle of issues from our 
own experience. Whether consider- 
ing the necessity of special aeromedi- 
cal support, or debating the differ- 
ences between the "clinician" and 
the "operator," similarities of con- 
cern were striking. "What kind of 
doctor he is in the ordinary sense of 
the word" was a phrase which sums 
up the method of some of the most 
effective flight surgeons. Those in- 
dividuals were clinically competent, 
mission-experienced, and intimately 
involved with the human dynamics of 
members of the unit and their fami- 
lies. That model, as awkward as it is, 



will remain the most effective one in 
many respects. The times, however, 
may have made the costs too great for 
such a model to be universally ap- 
plicable. 

The process of periodic recertifica- 
tion of competence is currently in 
process in our own aeromedical com- 
munity. 

The establishment of skill level 
designations for flight surgeons has 
been considered in the past by our 
own senior personnel, but has not 
been accepted. 

Continuing medical education is a 
priority subject in assurance of 
quality in our own efforts. 

As the Soviets commented on the 
quality of the very new flight sur- 
geons, they made an important 
observation. They advocated that 
young physicians work as junior 
members of a team before assuming 
roles alone. The experience of our 
own aeromedical and naval medical 
support community has shown that, 
in facilities where there is no experi- 
enced senior professional leadership, 
the quality of work accomplished may 
be less than desired. The task of pro- 
fessional and clinical direction of 
highly skilled and intelligent young 
physicians requires seasoned and 
sage leadership from individuals 
qualified and competent to earn the 
respect of their juniors. The absence 
of such mature clinical and profes- 
sional leadership deprives the de- 
veloping professional of a maturation 
factor of inestimable value. 

Insight into the personality of the 
Soviet aviator is revealed in the com- 
ment about pilots and "their known 
inclination to dissimulation." Human 
nature, apparently, is not changed by 
national boundaries or political 
ideologies. Most pilots want to fly, 
even when ill. A few don't want to fly 
at all. Telling the difference can be an 
interesting task for a physician. 

The need for increased skills in ac- 
cident investigation is a phenomena 
experienced in our own community. 
Translating academic and didactic 
exposure into action and actual per- 



Volume72,Mayl981 



J*tr«» 



•**. 




..►A 



KA/f-JlS "Forger" combat aircraft, wings folded, line Kiev's deck. 




formance is not a simple process. 

Support of aviation units assigned 
to aviation-capable ships is a common 
concern to modern seafaring nations. 
In those articles that discussed 
evacuation by helicopter from ships 
and submarines, there is a remark- 
able similarity of operational con- 
cerns. The litter lifts discussed sug- 
gested that both the Soviet and U.S. 
navies face the same difficulties. 



Conclusion 

Whether or not the literary essays 
in Soviet medical literature reflect the 
realities of day by day life of Soviet 
naval physicians is known only to 
those who serve in the new navy so 
well organized by Gorshkov. There is 
little doubt, however, that Soviet 
physicians must feel a strong sense of 
pride in their chosen work. A career 
in military medicine in the Soviet 



Union is said to be voluntary. Much 
effort is expended in planning for the 
indoctrination, training, and profes- 
sional work of the physicians, and 
much thought is invested in their 
leadership and military professional 
advancement. Such effort could 
hardly fail to have positive results. 

Thoughts of the Soviet military 
medical leadership were well ex- 
pressed in the following paragraphs 



U.S. Navy Medicine 



taken from an article describing a 
major meeting convened to explore 
and discuss the work of the military 
physician. The conference was de- 
signed to examine the qualities of the 
successful and respected military 
physician. The conference agenda 
centered on evaluation of the method 
and experiences of successful mili- 
tary physicians. 

New groups of military doctors — 
graduates of the military training 
institutions — are entering the 
medical service of the USSR 
armed forces on a yearly basis. 
They voluntarily enlist as military 
doctors. This is easy to under- 
stand: these young, still inexperi- 
enced people will work on the 
forward edge of the battle for the 
health of the troops. They will be 
direct conductors of party and 
government policy in the field of 
public health. 

These young doctors are in need 
of daily attention on the part of 
the chiefs and the senior com- 
rades, who must help them deter- 
mine their place in the military 
collective in the shortest possible 
time and acquire the practical 
work experience in their specialty. 
The success of the activities of the 
military doctor depends to a high 
degree on his respect from the 
command and the personnel of 
the chast. 

The conference ended with a call 
to all of the department students 
to persistently muster their mili- 
tary political, and specialized 
knowledge, to educate them- 
selves in the best features and 
qualities of the Soviet doctor, to 
preserve and multiply the glorious 
traditions of Soviet military medi- 
cine. (26) 

The preceding words express a 
portion of the emphasis on leader- 
ship, education, and training in the 
development of the young Soviet 
military physician. The concern of the 
Soviet leadership for improvement of 



their ability to provide physicians 
equal to the task of military medical 
support is clearly expressed. This 
paper has provided a glimpse of the 
effort directed toward naval medicine 
and the support of the Soviet fleet. 

Our own naval medical equation 
today is multifactorial. It is not the 
simplistic blend of sick call and salt 
tablets experienced by many naval 
physicians in the 50s and 60s. It is a 
bewildering mix of argon and beryl- 
lium, of behavior disorder and drug 
abuse, of habitability and leadership, 
of heat stress, noise and asbestos, of 
lasers and isocyanates, of blood 
gases and respirators, of pulmonary 
function, microwave and radiation 
monitoring, fatigue, of stress, and of 
limited material and human re- 
sources. The equation is not simple; 
it is incredibly complex. 

The demands currently before the 
Medical Department of the U.S. Navy 
are unrelenting. Their origins are as 
diverse as the tasks the Medical 
Department is expected to accom- 
plish. The matter of naval medicine, 
of how we do business at sea, exerts 
its demands with quiet persistence. 

The average member of our Medi- 
cal Department, if sent to sea for 
even a short time, would go with 
anxiety and uncertainty if unpre- 
pared for the experience. The un- 
familiar environment would present 
perplexing challenges. The process 
of earning acceptance among the 
ship's company would be an unfami- 
liar and sometimes awkward effort. 
Many tasks would be unlike those 
experienced in duty ashore. Why, 
then, would any individual be sur- 
prised to discover that work accom- 
plished was less than completely 
done? Lack of will would not be re- 
quired. Lack of knowledge and ex- 
perience, alone, would suffice to 
cause inadequate performance. 

Today, in our own Navy, we serve 
among a highly educated, intelligent, 
and dedicated group of naval profes- 
sionals. Sharing with them the chal- 
lenges of the new naval environment 
offers great opportunity and greater 



subjective rewards. Working to in- 
sure their health and safety in peace, 
and their survival and victory in com- 
bat, is an exciting and demanding 
discipline. 

We must insure that in research, in 
education, in naval medical organiza- 
tion, in selection of personnel for 
duty, and in the daily work of naval 
medicine we, like our Soviet counter- 
parts, constantly strive to remain 
"true masters of our craft." 

References 

1. Kopanev VI, Rudnyy NM, Vavilov II: 
Some peculiarities of training aviation doctors. 
VMZ no 8, pp 18-21, 1975. 

2. Ibid. 

3. Ibid. 

4. Ponomarenko VA: Specialized training 
of an aviation doctor. VMZ no 9, 1976. 

5. Kopanev, Rudnyy, Vavilov: Some pecu- 
liarities of training aviation doctors. 

6. Ibid. 

7. Dorofeyev GI: The clinical training of air 
physicians. VMZ no 3, 1977. 

8. Kopanev, Rudnyy, Vavilov: Some pecu- 
liarities of training aviation doctors. 

9. Ivanov NV, Kulesh AP, Titorenko MI: 
The training of an air physician. VMZ no 3, pp 
19-20, 1978. 

10. Dorofeyev: The clinical training of air 
physicians. 

11. Ivanov, Kulesh, Titorenko: The training 
of air physicians. 

12. Kopanev, Rudnyy, Vavilov: Some pecu- 
liarities of training aviation doctors. 

13. Ibid. 

14. Ibid. 

15. Ivanov, Kulesh, Titorenko: The training 
of an air physician. 

16. Ibid. 

17. Ibid. 

18. Ibid. 

19. Ibid. 

20. Kopanev, Rudnyy, Vavilov: Some pecu- 
liarities of training aviation doctors. 

21. Gorov AN: Discovery of the initial 
stages of overfatigue among the flight crew. 
VMZ no 3, pp 51-53, 1978. 

22. Grishin IR, Kozacha PG: Disturbance of 
fat metabolism in flight personnel. VMZ no 4, 
pp 50-51, 1978. 

23. Medical support of ships' helicopter 
crews with a single base. VMZ no 3, 1975. 

24. Guryanov AA: The evacuation of the 
sick and the wounded from naval and merchant 
marine ships by helicopter. VMZ no 4, 1967. 

25. Ivanov, Kulesh, Titorenko: The training 
of an air physician, p 20. 

26. Bortsov AP, Dadayev IM, Sukhanov NV: 
Conference on the work of the military doctor. 
VMZ no 4, p93, 1978. □ 



Volume 72, May 1981 



MSC Survey Results 

Attitudes Toward Professional Specialization 



LCDR P.T. Bruder, MSC, USN 



LT M.C. Butler, MSC, USN 



This is the fourth article in a series 
resulting from the Medical Service 
Corps survey conducted in April-May 
1980. 

In the last article, it was noted that 
approximately two-thirds of the sur- 
veyed officers regarded opportunity 
for education and training as one of 
the more important issues among 
career concerns. The question of who 
needs what type of special training, 
at what points in an officer's career, 
is also of importance to those in 
management responsible for officer 
career planning and development. 




Dietician LT Jeanine Brumbeau, MSC, 

counsels a patient. 



Even more essential, it is a matter of 
considerable consequence to the 
Navy Medical Department in meeting 
its mission requirements. Emphasis 
on continued education and training 
is the issue of specialization driven by 
accelerated advancement of knowl- 
edge and technology. This is certain- 
ly true in the field of health care with 
its myriad professions, including 
those which comprise the Medical 
Service Corps. The intent of the 
present article is to assess MSC offi- 
cers' self-perceptions and attitudes 
about professional specialization. 

In this analysis, attention was 
given the junior and middle grade 
officers with up to 13 years of com- 
missioned service (as defined in 
previous articles of this series). It is 
these officers who regard continued 
education and professional training 
as especially important in their career 
development. In addition to having 
the officers identify their specialty 
and subspecialty areas of qualifica- 
tions, two questions from the survey 
were of interest: (1) How specialized 
do you regard yourself at this time?; 
and, (2) How interested are you in 
further specialization? The officers 
responded to each question on a six- 
point rating scale. 



LCDR Bruder is the Head, Research Depart- 
ment, Naval School of Health Sciences 
(NSHS), Bethesda, MD 20014, LT Butler is a 
research psychologist at the Naval Health 
Research Center, San Diego, CA 92138. 

The authors wish to thank LCDR John 
Montgomery of the Naval School of Health 
Sciences, Bethesda, MD, for his computer 
programming asistance. 




Physiotherapist LT Carol Smith. MSC. 
assists patient who has recently under- 
gone knee surgery. 



Perceptions of Current Specialization 

The majority (70 percent) of junior 
(n = 673) and middle grade (n = 
482) officers who participated in the 
survey regard themselves as current- 
ly being more of specialists within 
their professions than generalists. No 
significant difference in those per- 
ceptions exists between junior and 
middle grade officers. Though there 
are a few more with doctorate de- 
grees among the junior officers, 
about 60 percent of both career stage 
groups have earned master's or 
higher graduate degrees in their spe- 
cialties (see U.S. Navy Medicine 72 
(2):3, February 1981). In listing the 
particular fields of their expertise, 



10 



U.S. Navy Medicine 



In talking with MSC officers, one 
of the more likely topics to emerge 
is that of professional specializa- 
tion. It is discussed in terms of 
billet requirements, career oppor- 
tunities for advancement, educa- 
tion and training, and personal 
interests. From conversations I 
have with our placement and 
assignment officers at the Naval 
Military Personnel Command 
(NMPC), I know it is a concept 
central to most reassignment 
transactions with the commands 
and the individual officers alike. 
Specialization is an interesting 
concept, too, in the sense that it is 
fraught with ambivalence — a 
source of great pride and con- 
fidence for some and a source of 
considerable anxiety for others. 

The propensity for technology to 
breed even finer technology has 
served as an inducement for 
trades and professions to corre- 
spondingly spiral to degrees of 
greater and greater specialization, 
much of which becomes institu- 
tionalized through unions and 
guilds into matters of licensure, 
certification, and other unique 
standards of qualification. Organi- 
zations, though they often lag 
other developments, tend also to 
move from simpler to more com- 
plex structures of specialized jobs 
and job relationships. The military 
has been no exception. Professor 
Kurt Lang used the term "tech- 



nocratic" to describe this process 
of "revolution in technology that 
has affected the structure of 
society no less than it has the mili- 
tary establishment."* The formal- 
ized impact on the Navy has been 
well noted in the enlisted rating 
structure for some time. In fact, it 
has been the source of consider- 
able manpower and personnel 
problems related to training, per- 
formance, and retention. To ob- 
serve the general impact on the 
commissioned officer structure, 
one needs only to note the high 
proportion of line officers with 
subspecialty qualifications in quite 
technical areas of expertise who 
are selected for senior grades (see, 
as a recent example, Navy Times, 
March 30, 1981, p 36). 

I alluded to these issues in my 
article on career planning pub- 
lished in the August 1980 issue of 
U.S. Navy Medicine. As a staff 
corps of the Medical Department, 
we perhaps have as complex a 
structure of professional speciali- 
zation as any cadre of officers. 
Nonetheless, as is true for the line 
officer community, there remain in 
the organization many require- 
ments for officers of relatively 
general skill and professional 



*Lang K: Technology and career manage- 
ment in the military establishment, in 
Janowitz M (ed): The New Military. New 
York, Russell Sage Foundation, 1964, p 40. 



capability, with an emphasis on 
breadth rather than depth of 
knowledge. For MSC officers this 
is true not only for those formally 
trained in fields of health care 
administration and management, 
but for those with academic de- 
grees in science and clinical pro- 
fessions as well. 

To plan careers and officer 
development resource require- 
ments, we must be sensitive to 
organizational requirements for 
various types and degrees of 
professional specialization. Those 
requirements, not the officers' 
interests, must be the driving 
force. At the same time, however, 
a comparable sensitivity to profes- 
sional interests and needs of our 
officers must also be maintained. 
It is for this reason that the 
present article derived from the 
MSC career attitude survey is so 
important. For, as complex as the 
issue of professional specialization 
is, the authors highlight a few of 
the variables that might be con- 
sidered in understanding officers' 
perceptions and attitudes about 
specialization. As with the other 
articles in this series, it is the 
intent that the observations dis- 
cussed will stimulate more ques- 
tions and further dialogue about 
these issues among our officers. 

P.D. Nelson 
CAPT, MSC, USN 



the officers identify with 48 different 
specialty and subspecialty areas. 

Does the type of profession or 
occupational field make a difference 
in how an officer perceives his or her 
current degree of specialization? It 
appears to, at least when referring to 
the MSC general occupational cate- 
gories of administration, science, and 
clinical professions as previously 
defined (see U.S. Navy Medicine 72 
(3):10, March 1981). Of the officers in 



clinical professions (n = 383), 86 
percent perceive themselves to be 
relatively specialized, in contrast to 
only 54 percent of those (n = 534) in 
the health care administration pro- 
fession. The science officers (n = 
236) are similar to those in clinical 
professions, 79 percent regarding 
their current professional capabilities 
as being more specialized than 
general. Within each of the three 
broad categories of profession, no 



significant difference was observed 
between self-perceptions of junior 
and middle grade officers or between 
officers procured from different 
sources (e.g., inservice vs direct ap- 
pointment). 

Interest in Further Specialization 

As specialized as these officers 
consider themselves to be presently, 
more than half (64 percent) express 
an interest in further specialization 



Volume 72, May 1981 



11 



TABLE 1. Perceptions and Interests of Junior and Middle Grade 
MSC Officers About Professional Specialization* 







Percentage Who 


Percentage Who 






Perceive Themselves 


are Interested in 


Officer Category 


N 


Presently Specialized 


Further Specialization 


Junior Grade 








Administrative 


283 


54 


72 


Science 


144 


78 


78 


Clinical 


246 


86 


74 



Total 



673 



72 



diddle Grade 






Administrative 


253 


52 


Science 


92 


79 


Clinical 


137 


86 



Total 



482 



67 



74 



42 
55 
66 

51 



within their professions. In this in- 
stance, however, officers differ by 
career stage, with 74 percent of the 
junior officers compared with 51 per- 
cent of the middle grade officers ex- 
pressing such interest. That general 
difference between officers of the 
junior and mid-career stage groups is 
significant as well within the profes- 
sional categories of health care 
administration and science officers; 
and though not statistically signifi- 
cant, the trend is there among 
officers of the clinical professions as 
well. Table 1 provides summary data 
on the various subgroups of officers. 
As with perceptions of their current 
degree of professional specialization, 
officers of clinical professions are 
most likely and health care adminis- 
tration officers are least likely to want 
further specialization. 



* Officers were coded as "specialized" in their self- perceptions and future interests if their re- 
sponses were above "3.5" on the respective 6-point rating scales. 



Photos by HM2 J. Parmenter, USN 




LT Sarah Gilman, MSC, adjusts TV camera atop hyperbaric chamber at the Naval 
Medical Research Institute, Bethesda, MD. 



Shifts in Perspective 

Though the survey was not de- 
signed to adequately assess if and 
how officers change their attitudes 
over time, the cross-sectional data 
suggest the likelihood of shifts in 
perspective as one progresses in a 
professional service career. In this 
instance, officers who expressed 
interest in further professional spe- 
cialization, regardless of how spe- 
cialized they perceive themselves to 
be presently, illustrate this point. As 
shown in Figure 1, there appears to 
be an almost linear negative relation- 
ship between officers' interests in 
further professional specialization 
and their age, a variable which is 
related to but not a perfect correlate 
of career stage in the Medical Service 
Corps. This is consistent with survey 
results reported in previous articles, 
namely those pertaining to a decline 
of interest in continued education and 
training from junior to senior officers. 

At this point, we can only speculate 
about the reasons for the decreased 
interest in specialization with age. 
One reason might be that as officers 
progress in their careers, they have 
already achieved the degree of spe- 
cialization they once desired as junior 



12 



U.S. Navy Medicine 



FIGURE 1. MSC Officer Interest in Further Specialization 



Very 6 

Interested 



Not 1 

Interested 



; ■ ' ^ 



25-29 



30-34 35-39 

AGE 



40-44 



Key: 



Clinical Specialties 

Science Specialties 
Administrative Specialties 



officers. On the other hand, their 
views toward generalization versus 
specialization may have become 
moderated by virtue of experience in 
their professions or by developing 
other priorities in their lives (e.g., 
family interests). Perhaps as likely, 
many officers' perceptions of ad- 
vancement opportunities and position 
requirements of the organization for 
more senior officers temper their in- 
terests in being highly specialized as 
they progress through a naval career. 
In any event, the reality of matching 
billet requirements with officer pro- 
fessional needs and interests must be 
dealt with by career planners and 
counselors as well as by the officers 
themselves. 

The information gained from ex- 
amining the responses will no doubt 
lead career planners to investigate 
the timing of specialty training as it 
applies to the variety of specialties 
we have within the Medical Service 
Corps. For example, specific con- 
siderations may be fruitful in areas 
like the following: 

• Examine the desirability of provid- 
ing officers with further specialty 
training very early in their careers. 

• Determine the degree to which 
early assignments to operational 
tours tend to motivate the officer 
toward greater specialty training. 

• Gain a better idea of the overall 
value gained in providing mid-level 
officers with additional specialized 
training. 

• Determine the generalist education 
requirements for all specialty clusters 
and determine at what point or points 
that education should be received in 
the career. 

Each new analysis should bring us 
closer to understanding the relation- 
ships between the officers and his or 
her career. It is a complex task. In the 
next article, we will examine the per- 
ceptions officers have of their simul- 
taneous professional roles as naval 
officer and staff corps specialist in 
the Medical Department. □ 



Volume 72, May 1981 



13 



Tri-SARF 

A Unique Facility Returns Patients to Duty 



It seems at first an unlikely setting 
for an alcohol treatment unit — the 
converted second floor of a bachelor 
enlisted quarters on the grounds of 
the National Naval Medical Center. 
But there is nothing unlikely about its 
highly professional staff and the way 
patients suffering from alcoholism 
are rehabilitated. 

The patients of the Tri-Service Al- 
coholism Rehabilitation Facility (Tri- 
SARF) are young and not so young, 
men and women, some in their first 
enlistment and a few near retire- 
ment. They are seamen, lance cor- 
porals, chief petty officers, Air Force 
staff sergeants, and Army privates. 
They are Navy commanders and 
Army colonels. Alcoholism, it seems, 
makes no distinction between age, 
social status, race, or sex. It is this 
unique aspect of alcoholism that 
makes it so treatable. 

Like almost all alcohol treatment 
programs in the Navy, the Tri-SARF 
emphasizes human relationships and 
the therapeutic value of allowing pa- 
tients suffering from this disease to 
interact. Mutual support is essential 
if alcoholics are to get well. 

In many respects, the Tri-SARF is 
not unique. Its curriculum and opera- 
tion are common to almost all Navy 
alcohol residential treatment facili- 
ties and is based on the model de- 
veloped at the Naval Hospital, Long 
Beach, CA, Patients are treated in 
the physical, mental, and spiritual 
aspects of the disease, and along with 
the therapy, there is firm discipline, 
The Tri-SARF too, has a number of 
recovering alcoholics on its staff. 
Having experienced the disease 
themselves, they are very qualified to 
help others recover from it. What, 
then, makes it different? Very sim- 
ply, the Tri-SARF is a successful at- 
tempt at interservice cooperation. 

Why the need for a tri-service 







\ 



' 



N 



U.S. Navy Medicine 




A daily program of physical conditioning helps patients feel good about themselves. 



program in the first place? In the mid 
1970s, the Washington, DC, area 
already had a large military popula- 
tion. The Army had no formal resi- 
dential program. As part of the Na- 
tional Naval Medical Center's psy- 
chiatry service, the 15-bed Navy in- 
patient program was also inadequate. 
The Air Force, too, needed some- 
thing better. 

In March 1977, the Surgeons 
General of the three services ac- 
knowledged that tri- service coopera- 
tion could help solve the problem. 
They acted shortly thereafter by con- 
vening an ad hoc committee to con- 
sider several sites for a common 
facility. 

By July 1977, the committee had 
selected a site at the National Naval 
Medical Center. The second floor of a 
bachelor enlisted quarters was reno- 
vated, staff members from all three 



services were selected, and by Sep- 
tember of that year, the Tri-SARF, 
the only alcoholism program de- 
signed to treat patients from all 
branches of the military, was a going 
concern. 

According to CAPT George 
Negron, MC, USN, the Tri-SARF's 
commanding officer and presently its 
only full-time physician, the opera- 
tion has been a valuable experience. 
In fact, one of its purposes, the en- 
couragement of cross-pollination be- 
tween Army, Air Force, and Navy, 
has been very successful. The now 
56-bed unit is a durable amalgam 
containing the best of each service. 
The Air Force donated the concept 
derived from its very successful after- 
care system. The Army contributed 
its family program designed to help 
treat those close to the alcoholic pa- 
tient. The Navy added its progressive 



philosophy and the recovering coun- 
selor concept. From birth, the Tri- 
SARF had an unbeatable combina- 
tion. 

The Treatment Program 

How do patients get into the Tri- 
SARF program in the first place? 
Some alcoholics correctly perceive 
their addiction as the destroyer of 
their marriage, family, and job. They 
either come on their own or the 
family intervenes and delivers an 
ultimatum such as described by LT 
Cindy Sennett, NC, USN, the unit's 
full-time clinical nurse: '"I love you,' 
the wife insists, 'and I want you to go 
for treatment. I can no longer live in 
this situation. If you don't go I am 
going to leave you.' The children, 
other relatives, and sometimes, even 
the alcoholic's boss, then have their 
say. At this point, the alcoholic usual- 



Volume 72, May 1981 



15 




Patients are responsible for maintaining their living areas. 



ly will agree to enter treatment." 

For those who have experienced 
the physical symptoms of alcoholism 
— blackouts, liver damage, gastritis, 
pancreatitis, ulcers, or severe mal- 
nutrition — the reality that alcoholism 
is a terminal illness comes as an im- 
mediate and frightening revelation. 
The decision not to enter treatment is 
a death sentence. 

More often, the alcoholic denies 
his illness but comes to the Tri-SARF 
because he is in trouble with the law 
or with his supervisor. His command- 
ing officer or supervisor then pre- 
scribes the alternatives: Enter treat- 
ment or be medically or administra- 
tively discharged from the service. 

Some patients are referrals from 
the National Naval Medical Center, 
other local military hospitals, or from 
bases in CONUS or overseas. 

The treatment program begins as 
soon as the patient checks into the 
unit. He or she is medically evaluated 
and is assigned a bed in the male or 
female sections of the ward, A pa- 



tient-sponsor helps with orientation. 
From the moment a patient enters 
the Tri-SARF until he or she leaves, 
drugs and alcohol are strictly for- 
bidden. Many patients are young, 
basically healthy individuals. "Re- 
move the alcohol and drugs," insists 
Roger Roark, the Tri-SARF's Clinical 
Coordinator, "and their own normal 
coping mechanisms take over." To 
aid that process, each morning, just 
prior to small group therapy sessions, 
the patients receive their daily dose 
of Antabuse, a drug that will bring on 
violent side-effects if mixed with 
alcohol, Antabuse is the Tri-SARF's 
insurance policy and most patients 
Find it a useful, if temporary, crutch 
to help them toward sobriety. 

Military discipline presides, with 
the customary musters, inspections, 
and details. During normal duty 
hours, each patient wears the uni- 
form of his service with one notable 
addition — a name tag with just a first 
name. Regardless of rank or grade, 
patients and staff call each other by 



first name on the unit. This symbol- 
izes that alcoholism does not respect 
position or social status. The uniform 
reminds them that they are still in the 
military and the primary reason they 
are in treatment is to get well and 
return to duty. 

The first two weeks, the staff 
evaluates the extent of the patient's 
illness and tries to break through 
denial. Getting the patient to freely 
admit his alcohol addiction is a 
formidable task. 

The duty day begins at 0630 and 
there are specific activities scheduled 
until at least 1700. A modified 
schedule exists for holidays and 
weekends. During these first two 
weeks, patients attend lectures, 
films, small group therapy sessions, 
a minimum of 14 AA {Alcoholics 
Anonymous) meetings, and engage 
in some form of vigorous daily exer- 
cise such as jogging, swimming, or 
basketball. The physical training pro- 
gram is aimed at reversing the pa- 
tients' physical deterioration brought 
on by their addiction. It also offers 
them some much needed positive re- 
inforcement. As they build their 
stamina, they begin to feel better 
about themselves. 

By the 14th day, the patients have 
also shared their autobiographies 
with their colleagues in the small 
group therapy sessions, an exercise 
that enables them to relate their 
backgrounds and drinking history. 

Staffing. The third week marks a 
significant milestone called Patient 
Staffing, a formal evaluation of the 
individual's progress in the presence 
of the assembled patient community. 
The patient sits before the group and 
his counselors and answer questions. 
The staff is looking for a recognition 
by the patient that he or she is in fact 
suffering from alcoholism. For many 
alcoholics it is a worrisome exercise, 
for the questions get right to the 
point and establish whether the 
patient has overcome denial. 

The evaluators also look for the in- 
dividual's willingness to continue in 
treatment. After being alcohol- or 



16 



U.S. Navy Medicine 



drug-free for two weeks, the alcoholic 
is in a much better position to make 
that decision. Almost all choose to 
stay. 

Before Staffing is completed, the 
evaluators ask the patient what he or 
she must do in the next four weeks to 
achieve recovery. Also, what does the 
patient intend to do about involving 
significant family members — spouse, 
adolescent children, and in some 
cases, parents, siblings, and close 
relations. Based on this "trial," the 
patient is allowed to remain, placed 
on probation, the "Critical List," or 
discharged from the program. 

Several elements can lead to dis- 
charge — being disruptive or unwill- 
ing to work in group therapy, con- 
sistently violating the rules of the 
unit, or the use of drugs or alcohol. 
Usually, however, after two weeks at 
the unit, most patients, even those 
that come unwillingly, determine that 
their two-week investment has been 



worth it and they will do what is re- 
quired to remain. Few are actually 
discharged before six weeks are over. 
Co- Alcoholic Participation. The re- 
maining four weeks are a busy time 
for the recovering alcoholic. Small 
group therapy and daily physical 
training continue as do the films, 
lectures, and AA meetings. But 
something new and very important is 
added — treatment for the spouse and 
children, and sometimes a parent. 
These "co-alcoholics" are as much 
victims of the disease as the alcohol- 
ic. They have suffered, perhaps for 
many years, their father's or hus- 
band's rages and stupors — and the 
shame. They have been the "en- 
ablers," making his excuses for 
chronic absences from work and un- 
dermining attempts to reverse the 
disease. Most importantly, they need 
help for their own sake. Helping the 
co-alcoholic recover from the effects 
of alcoholism is not only an act of 



compassion but a sound investment 
in the future sobriety of the recover- 
ing alcoholic and the future of his 
family. 

It is, then, in the third or fourth 
week that the patient is encouraged 
to have his spouse and/or children 
join him for treatment. In some 
cases, patients may use the military 
medical evacuation system to bring 
dependents to Bethesda. 

For the next four weeks, the co- 
alcoholics participate in the treat- 
ment program but not as residents. 
The local Housing Office maintains a 
list of private rooms for rent. Occa- 
sionally, arrangements are made to 
house them in nearby hotels, at the 
Walter Reed Inn, or the Navy Lodge. 
In addition to small group therapy, 
the co-alcoholics attend AA meetings 
to help them understand the alcoholic 
and Al-Anon meetings for their own 
sake. 

Therapeutic Pass. For the first two 



Watching People Get Well 



Roger Roark, social worker and 
Tri-SARF Clinical Coordinator, 
has been with the unit four and a 
half years. He finds the job partic- 
ularly gratifying because the 
therapy is often so successful that 
many patients show marked im- 
provement in a relatively short 
time. In fact, after only six weeks 
of treatment, between 70 and 80 
percent of those treated return to 
duty, well on their way to recover- 
ing from alcoholism. 

USNM: Tri-SARF's six-week pro- 
gram has a very impressive suc- 
cess rate. 

Mr. Roark: People get well here 
and they get well quickly. The 
changes we see in people's lives 
which they themselves are making 
within the framework we provide 



— changes they make in six weeks 
— are absolutely phenomenal! One 
of the consistant comments we get 
from the psychology interns who 
come through this unit for training 
is that they are really surprised 
how quickly people get well. They 
compare this to the traditional psy- 
chiatric ward in a hospital where 
people have much more serious 
problems and are much harder to 
deal with. Many come here with 
the idea that alcoholism is unbeat- 
able. They don't like alcoholics 
and they don't want to be around 
them. They come here and after 
six weeks they radically change 
their ideas. 

One of the things I noticed 
was the fact that you really treat 
the whole patient. There seems to 



be a well coordinated approach to 
the problem. 

We try to treat the patient 
spiritually, psychologically, emo- 
tionally, and, as a good social 
worker, I'd like to add, socially 
too. Their social relationships are 
very disrupted. They don't know 
how to have fun without alcohol or 
drugs. Most of their friends have 
been drinking friends. They now 
have to get a whole new batch of 
friends. It's the first time many of 
them have ever played without 
being drunk. Sometimes they are 
scared and don't know what to do. 
Some people don't know you can 
barbecue a hamburger without a 
beer in your hand. 

I've observed that when some 
patients check in here they seem 



Volume 72, May 1981 



17 



to have a very negative and intran- 
sigent attitude. How do you draw 
them out? How do you know when 
to push and when not to push? 
How do you handle a patient who 
is not making progress? 

That sometimes is hard to know. 
We have a patient here now who is 
very angry and withdrawn. He's 
also been physically abused in the 
past and is very vulnerable. You 
have to be very careful not to psy- 
chologically abuse that patient. 
It's sometimes very difficult to 



figure out how much to challenge 
someone's defenses and help him 
to join the group and participate. 
There's no one right way to do it. 
You have to assess the patient and 
based upon your past experience 
know when to do the challenging 
and when to do the supporting. 
Often, patients trust the caring of 
the other patients more than the 
caring shown by the staff. They're 
not sure why we care. They often 
think we care because we're paid 
to. Often, when we find a patient 



Photo by HM2 J. Parmenter 




Mr. Roark 



who is having a hard time being 
here, we do what we can to keep 
him here and in touch with what's 
going on. We let the other patients 
do a lot of work with that individ- 
ual. Usually, in a week or two they 
make a complete turnaround and 
wouldn't leave if they had to. 

The small group therapy session 
seems to be the focus of a lot of 
interaction. 

This is where we deal most 
directly with feelings and the staff- 
patient and the patient-patient 
relationships. 

What about those patients who 
don't make it through the pro- 
gram? 

Just because a person doesn't 
complete this program doesn't 
mean he won't recover. What the 
patients have gotten while they're 
here are the tools to deal with the 
illness once they are ready. Some 
will eventually come back into 
treatment either here, at another 
program, or they will start going to 
AA and do what they need to do to 
recover. Others continue to drink 
and get into trouble. Some of them 
die. 

Is it necessary for one to have 
been an alcoholic to understand 
what this disease is all about? 

This is an issue that comes up 
repeatedly at our staff meetings. 
On our staff, we have a balance 
between recovering alcoholics and 
nonalcoholics. I think the balance 
is important. I cannot truly under- 
stand what it is to be an alcoholic. 
What I think 1 know is how to help 
people who are suffering from that 
illness. The focus in our program 
isn't on being drunk. The focus is 
on being sober. That's what 
people are trying to learn here. 
This is not a program about not 
drinking. It is a program about 
living. 



18 



U.S. Navy Medicine 



weekends, all alcoholic patients re- 
main at the Tri-S ARF. After Staffing, 
those who are not on probation or the 
Critical List are encouraged to take a 
therapeutic weekend pass, to leave 
the unit, and interact with their fami- 
lies in a more natural setting. How- 
ever, they must agree to attend at 
least one AA meeting that weekend. 

Community Government, The em- 
phasis on discipline and responsibil- 
ity is reflected in the existence of a 
patient community government. Pa- 
tients periodically elect a Community 
Chairman, a Master at Arms, a Phys- 
ical Training Coordinator, and a 
Transportation Coordinator. The re- 
sponsibilities of these officials are 
many and varied but, suffice it to say, 
the concept of community govern- 
ment helps foster a spirit of group 
awareness and responsibility. 

Lectures and Films. Lectures and 
films on various alcohol-related topics 
are frequent. Staff members and out- 
side speakers address such subjects 
as the nature of alcoholism, the 
addictive personality, assertiveness, 
alternative lifestyles, and Alcoholics 
Anonymous. There is also a women's 
group that deals with specific prob- 
lems faced by female alcoholics and 
co-alcoholics. 

This regimen educates the alcohol- 
ic to the psychological and physical 
aspects of the disease and helps clear 
up myths and misconceptions. Some 
films like Symptoms of Sobriety 
alert the alcoholic to the signs of re- 
covery and help answer questions 
like "How do I know I'm getting 
well?" 

Yet as important as this didactic 
aspect of the program may be, 
nothing can substitute for the critical- 
ly important and highly effective in- 
dividual and group therapy sessions. 
Here is where the most effort is ex- 
pended in counselor-patient and pa- 
tient-patient encounters. Here is 
where the alcoholic must confront the 
hard issues of his drinking. Here is 
where much of the real progress is 
made. 

Small Group Therapy. It may be 



known in other contexts as group en- 
counter or group discussion. Here it 
is "Small Group" and it is an im- 
portant and hallowed tradition — a 
morning ritual that cannot be vio- 
lated. A dozen or so patients and a 
facilitator, usually a social worker, sit 
in a circle and deal with individual 
feelings — long pent-up emotions 
about broken homes and alcoholic 
parents and spouses, about physical 
and psychological abuse they have 
encountered, unresolved conflicts 
about themselves that may or may 
not have contributed to their alcohol- 
ism. Here too they discuss relation- 
ships — with their wives, husbands, 
children — newly formed ones among 
themselves and staff members. 

One young private violated a unit 
rule last night that prohibits patients 
from attending an off-limits activity. 
He is losing his therapeutic pass next 
weekend and is angry. He feels both 
the rule and his punishment are un- 
fair. His fellow patients disagree and 
freely chastise him. 

A newcomer, an Air Force major, 
sits slouched in a chair nearest the 
door. The facilitator asks him to in- 
troduce himself to the group. He 
grudgingly does so but insists that he 
is not an alcoholic at all and simply 
has a little trouble now and then 
holding his liquor. The others voice 
their skepticism. Tom is in denial, 
one of the primary symptoms of al- 
coholism and is not yet willing to 
admit the obvious, 

Another patient, whose assign- 
ment last night was to write her auto- 
biography, quietly reads a tale of 
family discord, a father who drank 
himself to death, and her own flirta- 
tion with alcohol, drugs, and suicide. 
She finishes the painful task, ob- 
viously relieved, Tears of sadness 
and understanding run down the 
faces of several group members. 
They understand. They've been there 
too. Gently, other group members 
begin to question her about what she 
has read and slowly the anguish 
eases. She speaks freely now with no 
shame. The tension is gone and there 



is laughter and wise-cracking. They 
are a family, sitting around the 
dinner table after a very trying day at 
the office, sharing good times and 
bad, comfort and compassion. To- 
morrow, someone else will sit in the 
"hot seat" and read, and be cross- 
examined, and come clean. Honesty 
is very sacred in Small Group. 

Personal Growth and Awareness 
Lab. Psychodrama, or role-playing, is 
another tool used in the treatment 
program. This afternoon, the patient 
community will take part in a session 
in which one patient will confront a 
personal problem, meet it head-on, 
and hopefully, with the help of his 
peers and the lab director, reduce 
that problem to its lowest common 
denominator. The director, in this 
case, a member of the unit's staff, 
casts the roles for the drama and im- 
provises the script. 

The protagonist is a 23-year-old 
male alcoholic who feels he has lost 
his self-respect, a commodity he 
desperately wants back. Under the 
director's experienced guidance, he 
confronts those individuals in his life 
that may have either positively or 
negatively affected him and perhaps 
contributed to his present mis- 
fortune. Those roles are played by 
the other patients. 

After about an hour and a half of 
confrontation, he begins to see his 
life from a slightly different perspec- 
tive. Everyone in the room may be 
emotionally spent, but one thing is 
certain. Something positive has oc- 
curred. The protagonist admits that 
his battered self-respect may not 
have been lost at all. It simply needs 
refurbishment. 

The exercise has not offered a 
miraculous cure at all. Where before 
there were doubts and total con- 
fusion, now there is some order and 
understanding of what needs to be 
done. What has happened this after- 
noon is but one positive step in a 
long, painful recovery. He and his 
fellow patients still have a lot of work 
ahead. 

(To be concluded in the June issue) 



Volume 72, May 1981 



19 



An Alcoholic's Last Chance 



When U.S. Navy Medicine inter- 
viewed him, Jerry R. was a patient 
at the Tri-SARF and had just com- 
pleted the six-week program. Curi- 
ously, he had been through an al- 
cohol treatment program at 
Bethesda several years before but 
afterward had returned to drinking 
and the familiar pattern of job and 
family problems. His latest bout 
with alcohol was far more serious. 
When he checked himself into the 
Tri-SARF, there was evidence that 
his liver had been affected, Jerry 's 
choice was simple. This time he 
had to recover, for a relapse would 
mean his premature death from 
alcoholism. 



USNM: I understand you have 
been here before. 
Jerry R.: I was here about eight 
years ago when the unit was 15 
beds and part of the psychiatry 
service. There were people in here 
with all kinds of psychiatric dis- 
orders. There were two counselors 
then. Shortly thereafter, the first 
psychiatric social worker came 
to work on the ARU (Alcohol 
Rehabilitation Unit) as it was 
called then. Most of our days were 
filled with looking at films on al- 
coholism. 

The difference between that 
program and this is totally dra- 
matic. They've taken the best of 
the Army's program where they 
bring in the family for treatment; 
the Air Force brings in their Social 
Actions Program and the two-year 
aftercare plans. The staff too has 
grown by leaps and bounds. 

I preceive a very dramatic 
change in treatment procedures. 
In those days, the alcoholic pa- 



tients gathered in one room on the 
psychiatric ward and we would 
have our own semi-AA meetings. 
There was no such thing as small 
group therapy. We didn't do psy- 
chodrama. We talked about AA 
and discussed how we would make 
the transition into AA when we got 
out. That along with the educa-. 
tional program and the physical 
examinations to determine what 
was wrong with us physically was 
the extent of the program. 

Today, it's the total treatment 
concept. I just could not under- 
stand at that time how alcoholism 
had entered into all my other rela- 
tionships. I perceived it solely as a 
character defect that had to be 
eliminated and AA would do that. 
The educational process is cer- 
tainly here. The biggest key is the 
small group and what we do with 
the therapists and facilitators. 
There are emotional break- 
throughs where you begin to see 
how behavior patterns are formed 
and perpetuated. 

The first time I left here I really 
thought I was not psychologically 
fit. I felt there was something 
wrong with me that made me drink 
the way I did. What I eventually 
learned was that I drank because I 
was an alcoholic, that my body had 
developed an intolerance to alco- 
hol. 

Did yon have a history of alco- 
holism in your family? 

No. My parents were both fun- 
damentalist Baptists and never 
drank. In the community where I 
grew up, everything was black and 
white. The people who drank were 
bad and the people who didn't 
were good. 



When did you take your first 
drink? 

In my case, I had a lot of emo- 
tional conflicts when I was grow- 
ing up and those scenes kept re- 
peating all the way through grade 
school. Because my mother played 
a dominent role, there was always 
a lot of conflict in our household. I 
felt that I wanted acceptance from 
my brothers and sisters more than 
anybody else and they totally 
rejected me. 

When I got to high school 1 got 
out of the family circle and found 
alcohol. I had two brothers. They 
kicked my ass all over the place all 
the time. The first time I drank, 
they stopped. 

That really meant something. 

It meant a whole lot to me. 
Adolescence was a very difficult 
time for me. We found some wine 
one day and drank it. You bought a 
bottle, threw the cap away, and 
drank until it was gone. 

The good things alcohol did for 
me passed in about three months. 
From that point on it was problem 
drinking. 

But I do remember trying to get 
sober. There were tearful scenes 
with my family — great admonish- 
ments like "Why are you doing 
this to us?" and severe beatings. 
Every time I promised them I was 
going to do better, I really meant 
it. But nothing worked. I finally 
dropped out of school and joined 
the Navy at 17. I really liked the 
Navy from the very first day. It 
was a disciplined organization. I 
knew exactly what was expected of 
me. The problems began as soon 
as 1 got out in the fleet and en- 
countered alcohol again. My pat- 



U.S. Navy Medicine 



tern was to save all my money, go 
ashore on liberty and drink it all 
up. A liberty was not complete 
unless I was drinking to uncon- 
sciousness. 

This undoubtedly got yon into 
serious trouble. 

Nothing other than coming to 
work late. I could never be any- 
where on time or get my gear 
straight. But I wanted to. This 
behavior was not a conscious 
rebellion against the military or 
anything like that. I just couldn't 
stay sober long enough to get 
things straight. 

I finally got busted and shortly 
thereafter married a gal who 
turned out to be an alcoholic. She 
was having blackouts. I never had 
blackouts. We would have terrible 
fights usually about booze. It was 
a terrible relationship. 1 could not 
accept the fact that she couldn't 
remember anything. 1 thought she 
was lying. 

Anyway, I got myself straight, 
at least as far as playing the mili- 
tary game and covering up my 
drinking. 

How did you do that? 

I learned to do two things — to 
make a concentrated effort at 
being where I was supposed to be 
and to wear a clean, sharp uni- 
form. I found that if you did those 
two things you cduld never get into 
trouble. People would stick up for 
you, go to bat for you. 

I eventually got out of the Navy. 
I had been in 10 or 11 years at that 
point and went to work for a TV 
station. The money was really 
miserable. I lied to get the job and 
told them that I had 'produced and 
been on camera. I thought if I 
hung around the station enough, I 
could learn what I had to. 

The pressure really got to me. It 



was much more demanding than 
the Navy had been so I decided to 
come back in and was assigned to 
a radio station overseas. 

Were you still drinking? 

Oh, yes, I was always on the 
brink of disaster. I even got drunk 
on the air one night. It was very 
bad scene. They were going to 
court martial me but waited too 
long to give me a blood test. I 
made my first AA contact and at- 
tended a meeting and they 
dropped the charges. I then went 
to the club to celebrate. 

I came back to the States and 
the booze and the weight were 
outrageous. I weighed about 260 
pounds and I couldn't wait till the 
end of the day to drink anymore. 

About that time, the Navy had 
announced its alcohol treatment 
program. When the instruction 
came out that said it wouldn't be 
punitive and that I could get treat- 
ment, I wanted it. 

Yet, even then, I remember 
feeling that I didn't really qualify 
for alcohol treatment because I 
was not that bad. I had a drinking 
problem but that was because I 
didn't have much will power. I felt 
I had to beef up my story once I got 
to Bethesda so I would qualify. 
Wasn't that a ridiculous thought? 

Everything around me was in 
confusion. I wanted to kill my wife 
(I had remarried), and my first 
wife, and everyone around me. I 
just wanted out. 

I spent the six weeks here, went 
to a few A A meetings. I did not 
want to drink anymore but was to 
miserable to stay sober. 

Wasn't AA enough? 

After the alcohol was gone, 
there was still me. The support 
systems dropped away one by one. 
I began drinking heavily again. 
About a year and a half ago I 



began to experience the pain in my 
side and I knew it was my liver. 1 
had peripheral numbness in my 
arms. But I was still functioning on 
the job, One night I realized I was 
losing the will to live. Everything 
in me that had made me scrap 
around and stay alive all these 
years was gone. 

You've been through the pro- 
gram again and seem optimistic 
that this time you've ticked the 
problem. 

My reaction about being here is 
one of intense relief. My wife has 
been here and I've really talked to 
her for the first time in 1 1 years. I 
don't dread going home anymore. 
I'm looking forward to getting out 
and doing some things, I decided 
that next year I'm going to hike 
the Appalachian Trail from begin- 
ning to end. My will to live has 
been regained. 

This is the way I want to live. 
The people I've met here and 
through AA are the people I prefer 
to be with. I never again want to 
lose my fear of alcohol. I have to 
do something with A A the rest of 
my life but I feel now I don't have 
to. I want to. 

What is it about the Tri-SARF 
that made the difference between 
now and what happened previous- 
ly? 

I think it's the right amount of 
everything. It is a well balanced 
program. I trust these people and 
sense a sincere dedication. These 
people, many of them, are re- 
covered alcoholics themselves and 
I'll always establish a link with 
someone in that situation. I know 
they are not talking down to me. 
They've treated me like a human 
being, with dignity and respect. 
Most of all, they've given me back 
responsibility for my life. 



Volume 72, May 1981 



21 



Alcohol Glossary 



AA (Alcoholics Anonymous) 

A worldwide self-help organization in which members 
help each other recover from alcoholism in a type of 
group therapy setting that utilizes common experi- 
ence for mutual support. 

Al-Anon 

An organization patterned after Alcoholics Anony- 
mous in which adult persons who have a significant 
relationship with an alcoholic help each other. 

AJ-Ateen 

An organization patterned after Alcoholics Anony- 
mous in which adolescent persons who have a signifi- 
cant relationship with an alcoholic help each other. 

Alcoholism 

A disease characterized by the dependence on alcohol 
and loss of control over one's drinking. It is this 
nation's number one drug of abuse. Recent estimates 
indicate that between 12 and 15 Americans suffer 
from alcoholism. 

Alcohol Rehabilitation Center (ARC) 

A separate command of the line of the Navy that pro- 
vides residential rehabilitation within a structured 
military environment. 

Alcohol Rehabilitation Service (ARS) 
A clinical service organized within a Naval Regional 
Medical Center or Naval Hospital that provides 
residential rehabilitation in a medical environment. 

Antabuse 

A drug (disulftram) used as part of an alcohol treat- 
ment regimen. It will cause an unpleasant reaction in 
the presence of alcohol, thereby aiding the recovering 
alcoholic to resist temptation. 

Ascites 

A by-product of chronic alcoholism characterized by 
the accumulation of serous fluid in the abdominal 
cavity. 

Blackouts 

A condition characterized by failure of vision, 
momentary unconsciousness, and loss of memory. A 
common by-product of chronic alcoholism. 

Cirrhosis 

The most serious or final stage of liver injury and de- 
generation. Chronic alcoholism is the most common 
cause. 



Co- Alcoholic 

A family member of an alcoholic. Co-alcoholics are 
both victims of and contributors to the disease. 

Counseling and Assistance Center (CAAC) 
Navy outpatient units that provide assistance to indi- 
viduals and their commands in the processing and 
disposition of personnel with alcohol and drug related 
problems. 

Denial 

The attempt by the alcoholic to convince himself and 
others that he is not a victim of alcoholism. Over- 
coming denial and admitting that one has lost control 
of his habit is the first step on the road to recovery. 

Drunkenness 

A temporary loss of control over one's physical and 
mental powers caused by excessive alcohol intake. 

DWI (Driving while intoxicated) 

A frequent legal problem faced by alcoholics. 

Enabler 

A compulsive friend or family member who aids and 
abets the alcoholic's addiction by coming to his or her 
rescue. The enabler denies the alcoholic the opportu- 
nity to suffer the consequences of his actions and seek 
help for the illness. 

Ethyl Alcohol (C2H5OH) 

The common ingredient in alcoholic beverages. It acts 
as a depressant drug that slows the activity of the 
brain and spinal cord. 

Hangover 

The body's reaction to excessive drinking. It may be 
characterized by gastritis, anxiety, fatigue, and head- 
ache. 

Intoxication 

The state of being poisoned, a condition produced by 
excessive use of alcohol. 

NASAP (Navy Alcohol Safety Action Program) 
A Navy educational and awareness program adminis- 
tered under a university contract designed to educate 
naval personnel to the dangers of alcohol. 

Pancreatitis 

Acute or chronic inflammation of the pancreas often 
caused by alcoholism. 

Rehabilitation 

A structured process whereby a person suffering from 
alcoholism is restored to effective service. 



Professional 



A Simple Technique for Measurement of 
Percent Body Fat in Man 

LCOL Howell F. Wright, USMCR Charles 0. Dotson, Ph.D, Paul O. Davis, Ph.D. 



In 1973, a research study titled Estimation of Relative 
Body Fat and Lean Body Weight in a U.S. Marine Corps 
Population, was conducted by Wright and Wilmore. (i) 
The abjective of this study was to develop an accurate, 
simple technique for estimating total body fat and lean 
body weight from anthropometric measurements which 
in turn could be used to predict ideal body weight. The 
original data were gathered from 297 male Marines ran- 
domly selected from the total population of Marines at 
the Marine Corps Development and Education Com- 
mand, Quantico, VA. 

The anthropometric assessments included nine skin- 
folds, fifteen circumferences, and nine diameters. Body 
density was determined using the underwater weighing 
technique as described by Goldman and Buskirk(2) and 
relative fat was estimated by the equation of Siri.(J) At 
the time of the original research, two problematical areas 
were present. First, the state-of-the-art analysis tech- 
nique was a form of stepwise multiple linear regression 
analysis which employed only forward selection of the 
best measures estimating the parameter being investi- 
gated. The second was that the original software package 
would only accept 35 measures; therefore, Wright and 
Wilmore were restricted to this number and consequent- 
ly eliminated 2 of the 37 variables that were actually 
available. Recent statistical developments indicate that 
the accuracy of estimating relative fat may be increased 
by employing nonlinear equations. These facts led one of 
the original authors (Wright) to believe that the possibil- 
ity existed for improving the prediction accuracy of the 
original Wright/Wilmore equations. Consequently, a 
study was undertaken to re-evaluate the original data, 
using current statistical theory and expanded software 



LCOL Wright is Executive Vice President of the Institute of Human 
Performance in Fairfax, VA 22031. Dr. Dotson is exercise physiologist 
and statistician at the University of Maryland, College Park, MD 20740. 
Dr. Davis is Director of the Institute of Human Performance. 




Dry land weight is taken before immersing subject in the tank. 



capability for the purpose of improving existing or 
creating better equations for predicting percent body fat. 

Procedure and Results 

The original 1973 research data had been maintained 
and was available for re-evaluation. Stepwise multiple 
linear regression procedures were employed in all cases 
to determine the most accurate equations for estimating 
percent body fat. The results are reported in Table 1. 

The multiple linear regression equation based on the 
best combination of skinfold, circumference, and 
diameter measures reproduces the same equation previ- 
ously derived by Wright and Wilmore (first equation, 
Table 1). These equations are the same despite the fact 
that Wright and Wilmore employed the older forward 
selection technique for determing the best measures 



Volume 72, May 1981 



23 



estimating percent body fat. In the present study, the 
stepwise, selection/elimination technique was em- 
ployed. In the forward selection procedure, the measure 
exhibiting the highest contribution to the estimation of 
percent fat independent of measures previously selected 
is selected next for inclusion in the estimation equation. 



The new stepwise analysis procedure selects not only the 
highest contributor for inclusion in the equation, but 
reviews measures previously selected for their current 
contribution to the estimation. It is not uncommon to find 
measures contributing significantly to the estimation of a 
dependent variable only to lose its importance after other 



TABLE 1. Revised Percent Fat and Lean Body Weight Equations Developed from 1973 
Marine Corps Data and Percent Fat Equations (N = 297) 



Equation 
Number 


Predicted 
Variable 


Measure 


Weight 


R 


S.E. 


1 


Fat, % 


Chest Skinfold (mm) 
Abdomen 2 Circumference (cm) 
Neck Circumference (cm) 
Thigh Skinfold (mm) 
Shoulder Circumference (cm) 
Constant 


0.235 
0.490 

- 0.581 
0.125 

- 0.202 
14.160 


.87 


3.08 


2 


Fat, % 


Chest Skinfold (mm) 
Thigh Skinfold (mm) 
Abdomen Skinfold (mm) 
Abdomen 2 Circumference (cm) 
Neck Circumference (cm) 
Constant 


.157 

.113 

2.067 

.331 

-.797 
-35.203 


.87 


3.08 


3 


Fat, % 


Abdomen 2 Circumference (cm) 
Neck Circumference (cm) 
Constant 


.740 

-1.249 

.528 


.81 


3.67 


4 


Weight (kg) 
(kg) 


Weight (kg) 

Abdomen 2 Circumference (cm) 

Constant 


1.044 

.673 

40.985 


.88 


3.49 


5 


Fat. % 


Weight (kg) 

Abdomen 2 Circumference (cm) 

Constant 


-.257 

.854 

-36.464 


.73 


4.48 



TABLE 2. Presentation of Error Inherent In Using Lean Body Weight 
Equations to Predict Percent Fat 



2-1 





Lean 


Error 


Percent Fat 


Error 


Mean Score 
-1 S.D. 
+ 1 S.D. 


64.996 
61.506 
68.486 


- 3.49 kg 
+ 3.49 kg 


16.58 
21.06 
12.10 


+4.48% 
- 4.48% 




















U.S. Navy Medicine 



variables have been selected. The present analysis there- 
fore validates the original equation derived by Wright 
and Wilmore as the most parsimonious equation based 
on all anthropometric measures useful in estimating per- 
cent body fat. 

Due to a maximum number limit in the regression pro- 
gram employed by Wright and Wilmore, only 35 of the 
37 anthropometric measures available were considered 
for estimation of percent body fat. In the present study, 
we were not required to operate under a maximum limit. 
The second equation reported in Table 1 gives the results 
of this expanded analysis. The abdomen skinfold 
measure replaces shoulder circumference from the 
previous equation as the best equation useful in estimat- 
ing percent body fat. The validity coefficients for the two 
equations are, however, identical. 

To isolate an equation useful in field situations for esti- 
mating percent body fat, only circumference measures 
were entered into the stepwise analysis. Equation 3 
reports the best equation that can be used under field 
situation restrictions. Only circumference measures at 
the abdomen and neck need be taken to estimate percent 
body fat with an R = .81 and a standard error of estimate 
of 3.67 percent. This latter equation yields an increase in 
the error of estimate of only .59 of one percent over the 
more involved multivariate equations in Table 1. 

Equations 4 and 5 report estimation results for percent 
fat and lean weight based on body weight and abdomen 
circumference. Equation 4 was previously derived by 
Wright and Wilmore and currently is used by the Marine 
Corps to estimate percent fat of males through the for- 
mula: 



Fat, % = (1 - 



Lean Wt. 
Total Wt. 



) x 100 



When an equation is generated to predict percent fat 
directly by forcing weight (kg) and abdomen 2 circum- 
ference (cm), the resulting R value is considerably 
lowered and the standard error is increased as shown by 
equation 5. 

As equations 4 and 5 clearly reveal, the high validity 
coefficient reported for estimating lean weight does not 
hold for estimation of perent fat. The discrepancy arises 
due to the fact that lean body weight and percent fat are 
measured in different units of measurement and possess 
different ranges of scores. The standard error of estimate 
is expressed as the typical error in estimation that may 
occur at the average value for the estimated variable. 
Accordingly, Table 2 shows the effect of plus or minus 
one standard error in estimating lean weight upon the 
corresponding percent fat estimate. 

The standard error for estimating percent fat directly 
from a corresponding estimate of lean body weight is 
+ 4.48 percent. These results point out the problem one 
encounters when attempting to interpret validity coeffi- 



cients resulting from the correlation of two variables. 
The R coefficient of .88 reported by Wright and Wilmore 
must be translated to a scale reflecting the units of 
measurement and range for percent body fat. When this 
transformation is accomplished, the R coefficient be- 
comes .73. This relatively low R coefficient and high 
standard error makes the weight and abdomen 2 circum- 
ference tables currently being used as a result of the 
original 1973 research less desirable than the abdomen 
and neck circumference equation developed in this 
study. Table 3 is provided for quick determination of 
percent body fat. 

Application of nonlinear regression procedures for the 
measures reported in Table 1 failed to yield equations 
significantly improving on the estimation of percent fat 
over multiple linear equations. This is contrary to the 
concept presented by other authors who have shown a 
curvilinear nature to anthropometric measurements. (4. 
5) These results, however, apparently reflect the fact 
that male Marines are more homogeneous in percent fat 
range and in age. 




The subject is instructed to fully exhale underwater. When this 
task is accomplished, the scale will read between 2 and 6 kg 
depending upon how muck fat the subject has to keep him 
afloat. 



Volume 72, May 1981 



25 




An anthropometer measures body diameter. 




250 


63 


55 


4 7 


39 


3 1 


23 


1.5 


75.5 


7.2 


6.4 


5.6 


4B 


40 


33 


25 


76.0 


8.2 


7.4 


6.6 


5.8 


5.0 


4 2 


34 


266 


91 


S3 


7.5 


6.7 


5.9 


5.1 


4.3 


22 


10 


9.2 


8« 


7.7 


6.9 


6.1 


5.3 


27 5 


11.0 


102 


94 


86 


78 


7.0 


6.2 


780 


11.9 


lit 


103 


95 


87 


79 


72 


2*6 


12.9 


121 


11.3 


10 5 


97 


89 


81 


290 


13 8 


13.0 


12.7 


11.4 


106 


98 


90 


295 


14 7 


13 9 


13.1 


124 


11 6 


108 


10 


300 


15 7 


14.9 


14.1 


133 


12.5 


11.7 


109 


305 


16.6 


15 8 


150 


142 


13 4 


12.6 


119 


31 


17.6 


16.8 


16 


15 2 


144 


136 


12.8 


315 


185 


17.7 


169 


16 1 


15 3 


14 5 


137 


320 


194 


18.6 


178 


17.1 


163 


155 


14 7 


32 5 


204 


19.6 


18.8 


18 


172 


16 4 


156 


33 


21 3 


705 


19 7 


18 9 


18.1 


173 


16 6 


33 5 


22 3 


21 5 


207 


19 9 


19.1 


18.3 


175 


3*0 


232 


22.4 


21 6 


208 


200 


19 2 


18 4 


34 5 


241 


23 3 


275 


21 8 


21 


702 


19 4 


350 


25 I 


24 3 


235 


227 


21 9 


21 1 


203 


355 


26.0 


75.2 


744 


23 6 


27 8 


22 


21 3 


380 


27 


26.2 


75.4 


24 6 


23 8 


23.0 


27 7 


MS 


27.9 


27 1 


263 


755 


24 7 


23 9 


23 1 


37.0 


288 


280 


77 2 


265 


25.7 


24 9 


24 1 


37 5 


29.8 


790 


782 


27 4 


266 


25 8 


75.0 


380 


30.7 


299 


29.1 


283 


27 5 


267 


26.0 


185 


317 


309 


301 


793 


785 


27 7 


26.9 


390 


32 6 


31 8 


31.0 


30.2 


29 4 


28.6 


27.8 


395 


335 


327 


319 


31.2 


304 


296 


288 


400 


34.5 


33.7 


329 


37 1 


31 3 


305 


297 


405 


354 


34 6 


338 


33 


322 


31 4 


307 


41.0 


36.3 


356 


34.8 


340 


332 


324 


316 


415 


37.3 


365 


35.7 


349 


34 1 


33 3 


32.5 


420 


38.2 


374 


366 


35.8 


351 


343 


335 


42S 


392 


384 


37 6 


36.8 


360 


3S2 


344 


43 


401 


393 


385 


37 7 


369 


361 


35.4 


43 5 


41 


403 


395 


387 


37 9 


37 1 


363 


440 


42 


41 2 


404 


396 


388 


380 


372 


44 5 


429 


421 


41.3 


405 


J9B 


390 


382 


450 


439 


431 


42 3 


41.5 


40 7 


399 


39 1 


455 


448 


44.0 


432 


42 4 


416 


408 


400 


♦60 


45 7 


45.0 


442 


43 4 


42 6 


418 


4t 


48.5 


467 


45 9 


45.1 


443 


435 


42 7 


41.9 


47 


47 6 


468 


460 


45 7 


445 


43.7 


47 9 


47 5 


486 


47 8 


470 


462 


454 


44 6 


43B 


480 


49.5 


487 


47 9 


47 1 


463 


45 5 


44.7 


48.5 


504 


49 7 


489 


48 1 


47 3 


465 


45.7 


49 


51 4 


506 


498 


490 


482 


47 4 


466 


49.5 


52 3 


51 5 


507 


49 9 


492 


484 


47 6 


50.0 


633 


575 


51 7 


509 


50.1 


49 3 


485 



A skinfold caliper in use. Here the instrument registers an 
8.4 mm iliac crest skinfold. 



On the basis of the present study, it can be concluded 
that the best equation for measurement of percent body 
fat of men in a field situation is one utilizing abdomen 2 
circumference and neck circumference. It should also be 
realized that considerable error can be expected if one 
uses a lean body mass equation to predict, through a 
transformation procedure, percent body fat. 
References 

1. Wright FH, Wilmore JH: Estimation of relative body fat and 
lean body weight in a United States Marine Corps population. Aero- 
space Med 45:301-306, 1974. 

2. Goldman RF, Buskirk ER: Body volume measurements by 
underwater weighing: Description of a method, in Brozek J, Henschel 
A (eds): Techniques for Measuring Body Composition. Washington 
DC, National Academy of Science, 1961. 

3. Siri WE: Body Composition from Fluid Spaces and Density. 
Berkeley, Donner Lab Med Physics, University of California Report, 
1956. 

4. Durnin JVGA, Womersley J: Body fat assessed from total body 
density and its estimation from skinfold thickness: Measurements on 
481 men and women aged from 16 to 72 years. J Nutr 32:77-97, 1974. 

5. Jackson AS. Pollock ML, Ward A: Generalized equations for the 
prediction of body composition, abstracted. Med Sci Sports 10:47, 
1978. □ 



26 



U.S. Navy Medicine 



TABLE 3. Percent Fat Prediction in Males 
from Abdomen and Neck Circumference 



1725 17,50 



Null I in. I 
1B00 1S25 



1925 19.50 



1 

3 1 


2 
' 2 


4 


































2.9 


21 


1 3 


5 
































3 B 


-o 


: 3 


1 5 


7 






























1 t 


« 


37 


2.4 


1 6 


8 





























57 


is 


< ! 


3.3 


1' 


u 


1 


2 
























6.7 


59 


5.1 


4 3 


3 & 


2.7 


i i 


1 1 


.3 






















7.6 


M 


8.0 


5.2 


4 4 


J« 


7B 


28 


1.3 


.5 




















p. 1 :- 


7.7 


6.9 


6 ; 


I.4J 


«G 


3S 


3 


72 


1 4 


e 


















I 5 


| 1 


79 


7.1 


8 g 


55 


4 7 


.19 


3.1 


|J 


1 5 


B 
















10 » 


96 


11.5 


80 


7 3 


B.5 


5 7 


49 


4 1 


32 


1M 


1.7 


9 


.1 












!! 1 


106 


98 


9 


8 3 


1 4 


6 


5a 


ID 


4 2 


1 4 


2.6 


I 8 


1.0 


3 










12 3 


11.5 


107 


9.9 


9 1 


8 3 


7 5 


6 1 


60 


5 2 


a 4 


3.6 


28 


20 


1 2 


4 








13.2 


124 


11 6 


10.9 


101 


9.3 


S.'j 


7 7 


69 


6.1 


53 


45 


3 7 


79 


71 


1 3 


5 






14.2 


13.4 


126 


11.8 


1! 


<e.7 


9.4 


86 


7 8 


TO 


62 


55 


4 7 


39 


31 


23 


15 


7 




15 1 


14.3 


135 


12 7 


119 


11 1 


10 4 


96 


38 


ac 


7 2 


64 


56 


*e 


40 


3.7 


24 


16 


8 


>6 1 


15.3 


14 5 


13 7 


17.9 


12 1 


113 


10,5 


1 7 


89 


8 i 


73 


65 


5 7 


50 


47 


34 


2.6 


1 8 


170 


16 2 


154 


14 6 


138 


130 


122 


11 4 


106 


95 


9 1 


8 3 


75 


6.7 


59 


5 1 


*3 


35 


27 


17.9 


17.1 


16.3 


156 


I4B 


140 


132 


12* 


11 6 


10B 


10.0 


97 


8* 


76 


6.8 


60 


57 


«S 


37 


IB 9 


18.1 


17 3 


155 


15 7 


14,9 


14 1 


13.3 


13 b 


11.7 


10.9 


101 


9* 


86 


7B 


10 


67 


54 


4.6 


19 S 


19.0 


18.7 


174 


16 6 


158 


16.1 


14.3 


13 5 


12.7 


119 


11 1 


10 3 


95 


87 


79 


7 1 


63 


5.5 


20.8 


20 


19.2 


1B4 


t?6 


16 8 


16.0 


15.2 


1*4 


13.6 


128 


120 


11 2 


104 


96 


B9 


8 1 


73 


6.5 


71.7 


20 9 


20 1 


19 3 


13 5 


IJ 7 


16 9 


16.1 


15 3 


1*6 


138 


130 


12 2 


11.4 


10 6 


98 


90 


B7 


74 


22 6 


21 8 


21.0 


703 


19 5 


IB 7 


17 9 


17 1 


16 3 


15 5 


14 7 


13 9 


13 1 


12 3 


11 5 


10 7 


99 


92 


8.4 


73 6 


22.8 


22 


21 2 


20.4 


19 6 


IB.B 


1B0 


17 2 


16 4 


15.6 


1*8 


14 1 


13 3 


12 5 


11 7 


109 


10 1 


93 


24.5 


23.J 


22.9 


22 1 


21 3 


20,5 


19.8 


19.0 


IB 7 


17* 


166 


15 8 


150 


1*2 


134 


126 


118 


11 


10 2 


25 5 


24.7 


23 9 


23 1 


27 3 


71,5 


207 


199 


191 


183 


175 


16 7 


159 


15.1 


■ 4 3 


136 


128 


120 


11 2 


26* 


256 


74 3 


24.0 


73 2 


27,4 


71.6 


20B 


200 


193 


185 


17.7 


169 


16 1 


15 3 


14 5 


137 


129 


12 i 


27.3 


265 


24.7 


2S.0 


242 


23 4 


226 


21 B 


21 


707 


194 


18 6 


178 


170 


16 7 


15* 


14 6 


138 


13 1 


263 


77 5 


267 


259 


25.1 


243 


23.5 


22 7 


71 9 


71 1 


203 


19 5 


18 8 


18.0 


17 2 


16 4 


15 6 


148 


1*0 


292 


28.4 


276 


268 


760 


752 


2*5 


23 7 


77 9 


77 1 


21.3 


205 


19 7 


189 


18 1 


173 


16 5 


15.7 


14 9 


30 2 


79.4 


78 6 


27.8 


77 


762 


25.4 


24.6 


23 8 


23 


22 2 


71 4 


206 


19 8 


19 


18 3 


l) 5 


16 7 


159 


31.1 


303 


79.5 


2S.7 


27.9 


27.1 


263 


255 


2*7 


7*0 


232 


22* 


21 6 


20.8 


200 


19 7 


18* 


176 


168 


32.0 


31.2 


30.4 


29.7 


28.9 


78.1 


27 3 


26 5 


257 


2*9 


24 1 


23 3 


72 5 


21.7 


209 


70 ■ 


19 3 


18 5 


176 


33 


32 2 


31.4 


306 


298 


79,0 


78.7 


27 4 


266 


258 


25 


2*2 


73 5 


227 


21 8 


21 1 


20 3 


195 


1BT 


33 9 


33.1 


32 3 


31.5 


30 7 


29.9 


797 


784 


77.6 


768 


260 


252 


24* 


236 


27 8 


72 


212 


704 


19 6 


3(9 


3* 1 


33 3 


32.5 


31.7 


30 9 


301 


293 


73.5 


77 7 


26 9 


26 1 


25 3 


2*5 


73 7 


73 


22 7 


714 


20 6 


358 


35.0 


34.2 


33 4 


32.6 


318 


31.0 


30.2 


294 


78. J 


27 9 


27 1 


76 3 


255 


2*7 


23 9 


73 1 


77 3 


215 


36.7 


35.9 


35 1 


344 


33.6 


32 8 


32 


31.2 


30 4 


296 


28 3 


780 


27 2 


26* 


75t 


24 8 


74 


737 


22 5 


37 7 


36.9 


36 1 


353 


345 


337 


329 


32.1 


31.3 


305 


29J 


289 


28 2 


27* 


266 


258 


250 


747 


23* 


38 .6 


37.8 


37.0 


36.2 


354 


346 


33 9 


33 l 


32 3 


31.5 


307 


299 


291 


28.3 


27 5 


767 


259 


25.1 


74.3 


39.5 


388 


38.0 


37 2 


36.4 


35 6 


34B 


34.0 


33 2 


32.4 


316 


308 


300 


292 


28* 


27 7 


269 


76 1 


753 


40 5 


397 


389 


38.1 


37 3 


36.5 


36.7 


349 


341 


33* 


32.6 


31 8 


310 


30.7 


79* 


286 


27 8 


270 


262 


41 4 


40.6 


398 


390 


383 


37 5 


36.7 


35.9 


351 


343 


33 5 


32 7 


319 


3! 1 


303 


795 


78 7 


27 9 


37.2 


42.4 


41 6 


408 


40.0 


392 


384 


37 6 


368 


360 


35.2 


344 


336 


37 9 


321 


3) 3 


305 


797 


7ft 


21.1 


43.3 


425 


41 7 


40.9 


40 1 


393 


385 


37 8 


370 


36.2 


3S.4 


3*6 


33 8 


33 


32 2 


31 « 


306 


298 


2)0 


44.7 


43 5 


427 


419 


41.1 


40 3 


395 


38 7 


37 9 


37.1 


363 


355 


3*7 


33 9 


33 1 


324 


316 


308 


300 


45.2 


444 


43 6 


42 8 


42,0 


41.2 


40.4 


396 


368 


381 


373 


36.5 


357 


349 


34 1 


33 3 


375 


31.7 


309 


46 1 


45.3 


445 


43 7 


43 


42 2 


41.4 


406 


39.8 


390 


38.2 


37* 


366 


35.8 


35.0 


342 


234 


37.6 


31 9 




Pulmonary function instrument deter- 
mines quantity of residual air trapped in 
the lungs after full exhalation. This 
buoyancy factor is subtracted from under- 
water weight before determining density. 



Volume 72, May 1981 



21 



To sBe Or Not To sBe 
(That is the Question!) 



CAPT Roger E. Alexander, DC, USN 
George W. Dennish, MD 



Infective endocarditis, an all-inclusive term which en- 
compasses the condition known as subacute bacterial 
endocarditis (SBE), is a serious disease with significant 
mortality. Because of its implications, there has been 
profound concern for the management of susceptible 
patients undergoing dental treatment. This concern has 
led the American Heart Association (AHA) and the 
American Dental Association (ADA) to modify periodi- 
cally the recommended antibiotic regimens for these pa- 
tients. 

Unfortunately, controversies, shifting philosophies, 
and changing recommendations have created a climate 
of confusion, abuse, and even noncompliance in some 
dental and medical offices. This situation is made more 
complex by a concern over potential litigation on the one 
hand, and uncertainty as to the efficacy of the recom- 
mended regimens on the other since they are based on 
subjective considerations and animal data, and not con- 
trolled human studies. (1, 8, 12) 

It is our intent to clarify some of the confusion sur- 
rounding SBE prophylaxis and to provide practical 
clinical guidelines for managing dental patients who may 
be susceptible. 

Rheumatic Fever. Rheumatic fever (RF) is an acute, 
nonsuppurative, systemic inflammatory disease which 
follows (2-3 weeks after) a Group A, beta hemolytic 
streptococcal pharyngitis, in a small percentage of pa- 
tients. It usually occurs between the ages of 5 and 18, 
and rarely before or thereafter. The exact pathogenesis 
is poorly understood, but is felt to have an immunologic 
basis. The disease is characterized by fever; a self-limit- 
ing, migratory polyarthritis; chorea; an external rash 
over the trunk, abdomen, head (erythema marginatum); 



Dr. Alexander is Head, Oral and Maxillofacial Surgery Department, 
MCRD Branch Dental Clinic, NRMC San Diego, CA 92136. 

Dr. Dennish, formerly with the Cardiology Service at NRMC San 
Diego, CA, is now in private practice at Scripps Memorial Hospital, La 
Lolla and Encinitas, CA. 



and/or a carditis which may result in permanent valvular 
damage. (//) Physicians are reportedly seeing fewer 
cases in recent years (13) but it is not known whether this 
is due to more aggressive antibiotic therapy or to more 
sophisticated diagnoses. RF can be difficult to diagnose 
and is often mistaken for other diseases. 

Scarlet fever is caused by a similar (erythrogenic- 
toxin-producing) microorganism, and is frequently 
placed in the same category of concern. It should not 
carry the same implication since the incidence of carditis 
is markedly less than with RF. 

Rheumatic Heart Disease. According to AHA statis- 
tics, nearly two million Americans have rheumatic heart 
disease (RHD). There is a tendency for many doctors to 
associate RF with RHD, automatically, but one does not 
necessarily follow the other. In this era of antibiotics, RF 
can occur without RHD; likewise, valvular damage can 
be found without a positive history of RF.(t?) Earlier 
studies documented that 63.6 percent of RF patients 
developed RHD, (//) but with the advent of more 
sophisticated diagnoses and effective antibiotic therapy, 
the incidence of carditis is lower today. (13) RF patients 
who don't develop carditis seldom get valvular damage. 
If there is no evidence of valvular damage, it is less likely 
that they will get RHD later (/"recurrences of RF can be 
prevented during the first few years after the initial 
infection. (9, 10) For this reason, some post-RF patients 
are given ongoing maintenance regimens with oral 
penicillin or benzathine penicillin injections. (//) These 
regimens are maintainance in nature and therefore 
inadequate as prophylaxis regimens for dental treat- 
ment. 

In a study by Feinstein et al, as reported by Noonan, 
(9) out of 181 patients who lacked detectable murmurs 
during their RF episodes none developed subsequent 
RHD; of 188 patients with detectable murmurs (indica- 
tive of valvulitis) 71 percent developed RHD. 

The most common RHD lesion is a proliferative, 
granulomatous reaction resulting in mitral stenosis and/ 



.28 



U.S. Navy Medicine 



or insufficiency. Aortic valvular involvement is the 
second most common lesion. The disease process doesn't 
simply include valves, however. The entire myocardium 
can become involved. Once the valve surfaces have been 
altered, flow characteristics change and those sites 
become susceptible nidi for subsequent growths from 
blood-borne organisms (i.e., infective endocarditis). 

Congenital Heart Disease. Certain structural abnor- 
malities of the heart, present from birth, can create an 
"environment" for the development of microbial 
colonies, not unlike the scarring secondary to RHD. The 
incidence of congenital heart disease (CHD) is estimated 
at 8 per 1,000 births. (13) Among the CHD conditions of 
particular concern are ventricular septal defects and 
patent ductus arteriosus, as well as coarctation of the 
aorta, tetralogy of Fallot, aortic and pulmonary stenosis, 
atrial septal defects, and complex cyanotic heart dis- 
ease. Cardiologists feel that certain repaired CHD de- 
fects (e.g., patent ductus and atrial septal defects, etc.) 
do not mandate prophylaxis after six months, unless 
residual murmurs are noted clinically, or prosthetic 
patches are used. (4, 6) An exception to the rule is 
coarctation of the aorta. 

Bacterial Endocarditis. Normal heart valves tend to 
become involved with acute bacterial endocarditis 
(ABE), usually from staphylococcal or pneumococcal 
organisms, whereas RHD/CHD-deformed valves are 
predisposed to SBE. The basic lesion is a vegetation of 
fibrin "mesh," with entrapped blood elements (e.g., 
platelets) and bacteria. The mesh tends to shield the 
organisms from the host defense mechanism, and the 
infection itself tends to depress the normal host reac- 
tion. (10) The surrounding tissues becomes inflammed 
and the involvement can extend to the chordae and even 
to the myocardium. The valvular damage can be so life- 
threatening as to require immediate surgery for removal 
of the valve. 

With treatment, mortality rates are reportedly 
between 17 percent and 65 percent, according to two 
compilations. (2, 10) Left untreated, the disease is con- 
sistently fatal. In the subacute form, colonization is 
normally by organisms of low pathogenicity (bacteria, 
yeast, fungi, or even rickettsia), whereas the acute form, 
the organisms tend to be extremely virulent. (13) 

Between 46 percent and 80 percent of SBE patients 
will give histories of previous RHD. (7) In one study, only 
10 percent had any history of prior dental care and 36.7 
percent had no previously diagnosed heart disease. (2) In 
at least two studies there was a predominance of males 
(77.6 percent) and Caucasians (96 percent) involved. (2, 7) 

Etiologic organisms have changing profiles. Although 
a high percentage of SBE cases are caused by Strep- 
tococcus viridens, in recent years there has been in- 
creased involvement by yeast, fungi, and gram negative 
bacteria. (7, 11) Drug abusers have a high rate of involve- 



ment with resistant staphylococcus strains. (7) 

Onset of the disease is gradual, with an irregular, low- 
grade fever and audible heart murmur being cardinal 
diagnostic signs and symptoms. Chills, sore throat, 
weight loss, fatigue, malaise, arthralgia, and/or petichial 
hemorrhages may also be present. Blood cultures (5 over 
a 24-hour period) (10) are usually positive if taken cor- 
rectly, but may be negative. 

Cardiovascular Prostheses. Patients who have under- 
gone extensive surgery for placement of cardiovascular 
prostheses (major vessel grafts, heart valves, etc.) 
appear to be at significantly higher risk to develop endo- 
carditis at the suture sites, than other patients. The in- 
fections tend to involve gram negative organisms 20 
percent of the time. (10) The implications of such infec- 
tions are immense because of the possibility that removal 
of the prostheses may be necessary. Furthermore, the 
infected adjacent tissues may not support a replacement 
prosthesis. Obviously, the prognosis in such a situation 
is ominous. For that reason, a more aggressive prophy- 
lactic regimen has been generated, hitting a broader 
spectrum of microorganisms (Regimen B). 

Bacteremia from Dental Treatment. Since valves that 
have been involved with RHD/CHD are susceptible to 
reinfection via a bacteremia from dental manipulations, 
great concern has been voiced over dental treatment. 
Although many articles have debated this cause-effect 
relationship since the early 1900s, the pathogenesis is 
still far from clear. There does not appear to be a totally 
reliable way of predicting which patients with structural 
heart disease will experience valvular infection, nor the 
specific causal events that will initiate it. Bacteremia has 
not only been documented secondary to dental treat- 
ment, but also following everyday functional occur- 
rences, such as chewing, brushing, and flossing. (1) 
Dentally speaking, bacteria most commonly implicated 
are staphylococci, beta hemolytic streptococci, and bac- 
teroides. (2) 

Clinicians have questioned the wisdom of repeated 
antibiotic exposures, since 46 percent of the oral orga- 
nisms in one study, and 69.5 percent in another, were 
shown to be resistant to penicillin. (2, 7) The AHA has 
recently reported more than 30 cases where "SBE 
Prophylaxis" failed, and presently has a retrospective 
evaluation and registration program in effect to evaluate 
the problem. (14) 

The History. The patient history on which most dental 
practitioners base their RHD evaluations is the most un- 
reliable index of all! Patients may think they have had 
RHD/CHD because "it sounds familiar," (10) or their 
physician thought a long febrile illness might be RF, or 
perhaps another member of the family had had the 
disease. In one study, only 24.3 percent of CHD/RHD 
patients knew they required antibiotic coverage. (4, 8) 
Without positive documentation, a patient's word that he 



Volume 72, May 1981 



29 



or she had RF with RHD involvement is often an insuffi- 
cient foundation on which to base a decision for a lifetime 
committment to prophylactic antibiotic therapy. Never- 
theless, some clinicians persist in advocating "blanket" 
premedication for all patients with only a vague RF his- 
tory, and confusion reigns supreme. 

The "Need" for SBE Prophylaxis. Although the topic 
is controversial, (d) the AHA and most contemporary 
cardiologists feel that even if a patient has had RF or 
scarlet fever, antibiotic SBE prophylaxis for dental treat- 
ment is not necessary unless there is documented history 
of RHD or current clinical evidence of a residual murmur 
(valvular damage). (4,5, 9, 10) Because the prophylactic 
regimens have not been proven in humans, because of 
the potential side effects of repeated antibiotic usage, 
and because of the rapid emergence of resistant strains 
(in as little as 24 hours), there has been a shift toward 
relative conservatism. The tendency toward overkill 
remains, however, because of the serious consequences 
and professional accountability in the courts. (/) 

The demonstration of resistant strains emerging with- 
in 24 hours (J) led to cardiologists and infectious disease 
specialists recently devising a revised approach to anti- 
biotic prophylaxis. (12) Members of the AHA committee 
that dealt with the problem note that the duration of the 
current regimen is so short that emergence of resistant 
strains is unlikely. (5) If longer courses of therapy or 
repeated usages are required, appointments should be 
made at least one week apart or the antibiotic should be 
alternated (penicillin, then erythromycin, then penicillin, 
etc.). (5) Timing of the prophylaxis dose is probably more 
critical, since the resultant bacteremias have been shown 
to occur only in the first 15 minutes. (5, 10) Dental officers 
should make special efforts to formulate a comprehen- 
sive treatment plan at the inception of treatment and 
coordinate the treatment with all involved parties, so that 
a maximum amount of work can be accomplished in a 
short time and with very few appointments. In these 
patients, modalities like "quadrant dentistry" are not 
only time-efficient but therapeutic. 

Who Gets Covered? In accordance with published 
guidelines (12) the following patient must be premedi- 
cated with appropriate antibiotics before all dental pro- 
cedures likely to cause gingival or pulpal bleeding (in- 
cluding dental cleanings): 

• Patients with a history of rheumatic heart disease, or 
rheumatic fever and clinically evident valvular damage 
(i.e., present murmur). 

• Patients with documented congenital heart disease 
(see discussion above), 

• Patients with documented ideopathic hypertrophic 
subaortic stenosis or Barlow's Syndrome (prolapsed 
mitral valve) {Note: Incidence of SBE has been very low 
in the latter, and the need is controversial — the manag- 



ing physician should provide guidance as to need). 

• Patients with prosthetic heart valves, major vessel 
grafts, or other cardiovascular devices. 

• Possible need: Patients with indwelling vascular 
catheters, transvenous pacemakers, patients with 
shunts, etc. — implementation at the discretion of the 
consulting physician. 

Children shedding deciduous teeth, minor noninvasive 
procedures such as adjustment of orthodontic bands, 
etc., and procedures that do not produce invasion of soft 
tissues do not require prophylaxis, even in susceptible 
patients. Coronary bypass patients, adults or children 
with functional flow murmurs, and patients without 
demonstrable post-RHD murmurs but having tenuous 
history of RF do not require premedication with antibi- 
otics without cause. 

Evaluating the Need. Patients with CHD, cardiovas- 
cular prostheses and other serious heart conditions will 
normally have well-documented histories, complete 
medical charts, and will be well briefed on their condi- 
tion. The patients that will pose clinical dilemmas are 
those with very nebulous histories of rheumatic fever 
and/or heart murmur. It is this latter group of patients 
that will be the focus of our attention. 

Initial probing by the dental officer should ascertain 
whether the patient is relating a primary, secondary, or 
tertiary history, i.e., "1 remember . . ." vs "My mother 
told me that . . ." vs "My mother told me she remem- 
bers the doctor thought . . . ." Historical detail should be 
probed in depth. 

• Was the patient ever bedridden or hospitalized for RF/ 
RHD? 

• Was the patient ever restricted from sports? 

• Did the patient ever receive antibiotics on a regular 
basis over a long period of time? 

• Was the patient specifically advised that he/she had a 
heart murmur? 

• Was a murmur detected during the induction physical 
examination for active duty? 

• Was the patient sent to a consulting medical specialist 
for further evaluation? 

If the answers to these questions lend credibility to a 
history of RHD, then the patient's medical records 
should be obtained and perused. Every active duty pa- 
tient undergoes a physical examination at the time of 
induction and those records are generally available from 
the local dispensary or medical department facility. 

If the history to this point is suspicious, and medical 
records are either not available or not helpful, then 
consultation with the patient's managing physician or a 
military medical referral center is indicated before in- 
stituting dental treatment. This written consultation (SF 



30 



U.S. Navy Medicine 



513) should indicate the positive nature of the history ob- 
tained. Request an opinion as to whether this patient will 
require SBE antibiotic prophylaxis before future dental 
appointments, in accordance with AHA guidelines. The 
written reply containing examination findings (murmur, 
etc.) and the recommendations should be inserted into 
the dental record for future reference. 

If the referring dental officer notes an apparent con- 
tradiction in the advisory (e.g., a prophylaxis recom- 
mendation in the absence of demonstrable murmur), he/ 
she shouldn't feel reluctant to contact the consulted clinic 
and seek clarification regarding the recommendation. In 
the past, the senior author has encountered physician's 
assistants and physicians who were unaware of the cur- 
rent philosophies within the cardiology and infectious 
disease specialties. After discussion and further investi- 
gation, the recommendations for prophylaxis were sub- 
sequently modified. If the consulted physician feels that 
there are grounds for antibiotic coverage, then that 
opinion should be followed. 

The Antibiotic Arsenal, Based on the microbial popu- 
lation most commonly associated with dental bactere- 
mias and despite years of abuse, penicillin remains the 
antibiotic of choice in nonallergic patients. Although the 
parenteral route is preferred over the oral route, the 
latter is generally more favored by both the patient and 
the dentist. The subject of oral coverage is controversial, 
but the consensus seems to be that the oral route can be 
used without concern in reliable patients. In patients 
with a documented or suspected history of penicillin al- 
lergy, erythromycin becomes the favored drug, although 
some experts question its efficacy because of demon- 
strated resistance by common organisms. {10) Tetracy- 
cline, cephalosporins, and clindamycin are not approved 
drugs for SBE prophylaxis use, unless laboratory studies 
specifically indicate their necessity. Regimen B advo- 
cates usage of parenteral penicillin plus streptomycin. 
Many cardiologists believe that ampicillin and gentamy- 
cin are preferable to that combination, despite the 
AHA's failure to recognize that treatment program. (8) 
For patients allergic to penicillin, Regimen B utilizes 
vancomycin based on the organisms commonly encoun- 
tered. 

The Current AHA Regimen. The latest SBE prophy- 
laxis regimen from the American Heart Association 
(Table 1) features higher dosages of all drugs, given over 
a shorter time period, in order to minimize resistant 
strain emergence and cope with newer strains that have 
already developed. The recommendations are general in 
nature and not intended to cover all situations that may 
arise clinically. Duration and dosage of antibiotics must 
also take into consideration such factors as host 
resistance, clinical situations (e.g., abscess I&D), pa- 
tient's oral hygiene status (filthy vs clean), etc. Close 
rapport between medical and dental officers is manda- 



TABLE1. Current AHA/ADA SBE 
Prophylaxis Regimens (12) 

Regimen A. For All Susceptible Patients (Except 
Prosthetic Valve Patients) and Patients on Continu- 
ing Doses of Maintenance Penicillin 

Adults and Children Over 60 Lbs. 

Penicillin V, 2 gms orally 30-60 minutes preop, then 

500 mg Q 6 h X 8 doses 

(or) 
Aqueous (Crystalline) Penicillin G, 1 million units 
IM, plus Procaine Penicillin G, 600,000 units IM — 
both given 30-60 minutes preop, then Penicillin V 
500 mg Q 6 h X 8 doses 

Children Under 60 Lbs. 

Penicillin V, 1 mg 30-60 minutes preop, then 250 mg 

Q 6 h X 8 doses 

(or) 
Aqueous Penicillin G, 30.000 units per kg(BW) IM, 

plus Procaine Penicillin G, 600,000 units IM— both 

given 30-60 minutes preop, then Penicillin V, 250 

mg Q 6 h X 8 doses 

Alternate Regimen A: For Patients Allergic to Peni- 
cillin or Requiring Alternate Drugs 

Adults and Children Over 60 Lbs. 
Erythromycin, 1 mg orally lVi-2 hours preop, then 
500 mg Q 6 h X 8 doses 

Children Under 60 Lbs. 

Erythromycin, 20 mg/kg(BW) orally IV4-2 hours 
preop, then 10 mg/kg(BW) Q 6 h orally X 8 doses 

Regimen B: For All Patients with Prosthetic Heart 
Valves, Grafts, and Patients on Continuing Doses of 
Penicillin, for Whom Erythromycin is Not Indicated 

Adults and Children Over 60 Lbs. 

Aqueous (Crystalline) Penicillin G, 1 million units 
IM, plus Procaine Penicillin G, 600.000 units IM, 
plus Streptomycin, 1 gm IM — all given 30-60 min- 
utes preop, then Penicillin V, 500 mg Q 6 h X 8 doses 
(or) 

(Some cardiologists prefer an alternate regimen, 
using Ampicillin and/or Gentamycin — see text) 

Children Under 60 Lbs. 

Aqueous Penicillin G, 30,000 units per kg(BW) IM 
plus Procaine Penicillin G, 600,000 units IM plus 
Streptomycin. 20 mg/kg(BW) IM, given 30-60 min- 
utes preop, then Penicillin V, 250 mg Q 6 h X 8 doses 

Alternate Regimen B: For Patients Allergic to Peni- 
cillin and/or Streptomycin 

Adults and Children Over 60 Lbs. 

Vancomycin, 1 gm W over 30-60 minute period be- 
fore procedure(s), then Erythromycin . 500 mg 
orally Q 6 h X 8 Doses 

Children Under 60 Lbs. 

Vancomycin, 20 mg/kg(BW) IV over 30-60 minute 
period prior to procedures, then Erythromycin, 10 
mg/kg(BW) Q 6 h X 8 doses (NOTE: Vancomycin 
dosage not to exceed 44 mg/kg/24-hour period) 



Volume 72, May 1981 



tory for maximum patient benefit. (5) It must also be re- 
membered that infective endocarditis can occur in pa- 
tients receiving the recommended regimen. (72) There- 
fore, these regimens must go hand in hand with close 
clinical observation and followup. Again, it is empha- 
sized that the majority of specialists feel that patients 
with RF history alone and no demonstrable clinical mur- 
mur do not require SBE prophylaxis. 

Despite over 60 years of animal studies, professional 
consideration, and debate, medical specialists are still 
struggling to clarify the problems connected with infec- 
tive endocarditis, especially in the area of prevention and 
dental treatment. Changing protocols and shifting philo- 
sophies have led to confusion in the dental profession 
as to what patients require antibiotic premedication for 
the prevention of SBE subsequent to dental treatment. 
This paper has explored the various facets of the problem 
and outlined a rational clinical approach to patients who 
indicate on their histories that they have a history of 
rheumatic fever, rheumatic heart disease, congenital 
heart disease, or cardiovascular prostheses. This ap- 
proach is then integrated with the current prophylaxis 
recommendations of the American Heart Association. 



References 

1. Bornfield M: Letter to the editor. JADA 96:27, January 1978. 

2. Falace V. Ferguson T: Bacterial endocarditis. Oral Surg 42:189, 
1976. 

3. Garrod L, Waterworth P: The risks of dental extraction during 
penicillin treatment. Br Heart J 24:39, January 1962. 

4. Glasser S: The problems of patients with cardiovascular disease 
undergoing dental treatment. JADA 94:1 158, June 1977. 

5. Kaplan E, Durack D: Letter to the editor. JADA 96:28, January 
1978. 

6. Millard H: Preventive measures for bacterial endocarditis 
(questions and answers). JADA 89:S27, September 1974. 

7. Mostaghim D. Millard H: Bacterial endocarditis: A retrospective 
study. Oral Surg 40:219, August 1975. 

8. Neu H: Endocarditis: The problems remain and multiply. Infec- 
tion 7(2) :52, 1979. 

9. Noonan J: Natural history of rheumatic heart disease in adoles- 
cents. Postgrad Med 56:107 ', November 1974. 

10. Panky G: The prevention and treatment of bacterial endocarditis. 
Am Heart J 98:102, July 1979. 

11. Tarsitano J. O'Hara J Jr: Rheumatic fever: In depth appraisal 
with a discussion of penicillin. JADA 77:1074. November 1968. 

12. Prevention of bacterial endocarditis. Committee Report of the 
American Heart Association. JADA 95:600. September 1977. 

13. The Merck Manual of Diagnosis <$ Therapy, ed 13. Merck Sharp 
& Dohme Research Laboratories, 1977. 

14. Antibiotic failures sought. ADA News, March 17, 1980. D 



Maintaining Competent Surgical Support 



Continuing education and train- 
ing are necessary for optimum 
performance in many highly tech- 
nical jobs. Carrier qualified pilots 
are required to have made a night 
landing within the preceeding 
week to be fully qualified.* They 
usually fly many times each week. 
In addition, fliers often talk shop 
at meal-time, in the wardroom, 
etc.; the same as physicians do. 
Reserve military personnel who 
had satisfactory proficiency in a 
military skill during their active 
duty years, and who drill regular- 
ly, usually require three months of 
intensive additional training to 
bring their military skills to a 
satisfactory level. Physicians also 
learn and maintain their skills best 
by daily practice in an environ- 
ment of teaching conferences, pro- 
fessional consultations, and in- 
formal discussions among their 
peers. The availability of a good 



'NATOPS Manual. Landing Signal Officer, 
15 Nov 1975 



medical library is likewise impor- 
tant. Many State medical societies 
require continuing education for 
licensure, and many of the medical 
specialty boards require periodic 
formal reexamination to assure 
competence. 

Certain ships at sea and isolated 
land bases require the presence of 
a fully trained surgeon. A surgeon 
is needed for the occasional emer- 
gency — vehicle accident, explo- 
sion, fire, or of course actual war, 
but their day to day level of profes- 
sional activity usually is quite low 
— not enough to maintain com- 
petence for any more than a few 
months at a time. 

At these isolated facilities there 
is little organized educational 
activity, the reference library is 
barely adequate at best, and phy- 
sician to physician stimulation by 
discussion, argument, etc., is 
much less than at a teaching hos- 
pital. 

In short, while the line people 
are continually training, practic- 



ing, and drilling to maintain their 
skills, the medical officers in an 
isolated post are not (and cannot). 
The quality of emergency surgical 
care may be less than optimal, 
physician morale will decline, and 
retention of desirable medical offi- 
cers be more difficult. 

Recommendations 

Top quality surgical skills may 
be needed quickly although infre- 
quently at many isolated military 
installations. It is difficult for a 
medical officer, particularly a sur- 
geon, to maintain his skills in this 
type environment. Assignment to 
these isolated billets should be for 
three months or less and the phy- 
sician's other assignment should 
be to a naval regional medical 
center, preferably one with a 
teaching program. Financial or 
educational incentives would help 
fill these billets with qualified 
volunteers. 

— CAPT Robert L. Glass. MC, USNR, 
Department of Surgery. NNMC Bethesda, 
MD 20014. 



■A2 



U.S. Navy Medicine 



Notes & Announcements 



1NMEM0RIAM 

CAPT Thomas E. Bollinger, DC, USN, former oral 
surgeon, died 22 Feb 1981 as a result of a skiing acci- 
dent. 

Born 16 Nov 1938 in Omaha, NE, CAPT Bollinger 
received his D.D.S. from the University of Nebraska in 
1963. 

CAPT Bollinger was commissioned a lieutenant in the 
U.S. Navy Dental Corps on 1 June 1963 and was 
promoted to captain on 19 June 1979. His duty assign- 
ments included Naval Administrative Command, Naval 
Training Center, Great Lakes, IL; Naval Air Station, 
Agana, Guam; Naval Support Activity, DaNang, 
Vietnam; USS Dixie (AD-14); NRMC Great Lakes, IL; 
and USS Enterprise (CVN-65). 

CAPT Bollinger served as a staff member of the Dental 
Service at NRMC Oakland, CA, from May 1979 until the 
time of his death. 

LT John J. Treszka, DC, USNR, died 6 April 1981 in El 
Toro, CA. 

Born 11 Aug 1949 in Chicago, IL, LT Treszka received 
his B.S. degree from the University of Texas of El Paso in 
1972, an M.S. from the University of New Mexico in 
1975, and a D.M.D. from Tufts University School of 
Dental Medicine, Boston, MA, in 1979. 

LT Treszka was commissioned a lieutenant in the U.S. 
Navy Dental Corps on 2 Oct 1980 and was stationed with 
the 13th Dental Company, 1st Dental Battalion, 1st Force 
Service Support Group, FMF, EI Toro, until the time of 
his death. 



CONSTRUCTION OF NAVY MEMORIAL 

Recently, a resolution was signed by the Chairman of 
the Board of Directors of the Pennsylvania Avenue 
Development Corporation approving construction of a 
memorial in Market Square Park, on Pennsylvania 
Avenue between 7th and 9th Streets in Washington, DC, 
to honor those who have served the United States Navy. 

The U.S. Navy Memorial Foundation's proposal for 
the memorial features an amphitheater and stage that 
will become a permanent performance home for the Navy 
Band, provide facilities for other concert organizations 
(both military and civilian), and a water park designed to 
stimulate street life and make Market Square a center for 
public activities. 

The idea of creating a Navy memorial dedicated not 
only to the historic but to the continuing contributions 
and sacrifices made by Navy personnel and Navy 
civilians to our country's welfare has been discussed for 
many years. The project moved beyond the idea stage in 



1977 when the U.S. Navy Memorial Foundation was in- 
corporated as a nonprofit educational association. 
The approval is subject to the following conditions: 

• The Foundation must schedule the programming, 
funding, and approvals for the Navy Memorial in coordi- 
nation with and without delaying the Corporation's 
schedule for design and construction of Market Square. 

• The design of both the Navy Memorial and Market 
Square will be produced by a consultant selected jointly 
by the Foundation and the Corporation in accordance 
with the Corporation's Architect/Engineer selection 
procedures. Design of the Navy Memorial shall satisfy 
the design criteria for Market Square prepared by the 
Corporation in consultation with the Foundation. 

• The Foundation must furnish the Corporation with 
evidence and guarantees of sufficient funds for design of 
the Navy Memorial, at such time as design of Market 
Square and the Navy Memorial begins, and for comple- 
tion of construction at such time as construction docu- 
ments for Market Square and the Navy Memorial are 65 
percent complete. 

DIVING CASUALTY COURSE 

A course entitled Recognition and Treatment of Diving 
Casualties will be held 31 Aug 1981—4 Sept 1981 at the 
Naval Diving and Salvage Training Center, Panama City, 
FL. 

The course is for physicians interested in learning to 
recognize and treat basic diving casualties. The course 
would be beneficial to a physician with duty at a facility 
engaged in diving operations without the full-time avail- 
ability of an undersea trained, diving medical officer. 

The program is accredited through the Undersea Med- 
ical Society for 29-30 CME credit hours. The course must 
be approved and funded by the physician's command. 

For further information, write or call: Dr. William 
Cunningham, Undersea Medical Officer, Naval Diving 
and Salvage Training Center, Panama City, FL 32407. 
Telephone: (904) 234-4651. 

NACAP KITS AVAILABLE 

NaCAP (Navy Clearing the Air Program) kits for help- 
ing smokers quit smoking are available in limited quanti- 
ties. The kits contain informational booklets on smoking 
and health, audiovisual and print materials catalogue, 
brochures, self-help kits, "how-to" booklets, decals, 
buttons, etc. 

Any command wishing to obtain NaCAP kits should 
send their request to: CAPT D.F. Hoeffler, MC, USN, 
Bureau of Medicine and Surgery (MED 03B), Depart- 
ment of the Navy, Washington, DC 20372. 



Volume 72, May 1981 



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